What is Adenomyosis?
Adenomyosis, also referred to as “uterine endometriosis,” is a benign disease confined to the uterine muscle. Endometrial cells from the lining of the endometrial cavity, migrate from that lining, most commonly into the posterior side or back wall of the uterus. As these cells respond to monthly hormonal changes, blood can get trapped in the myometrium producing a hard and enlarged uterus. Adenomyosis is most frequently seen in women in their early to middle 40s and is often associated with hormone imbalance…usually an excessive estrogen supply. Various published studies have shown that 12% of patients with Adenomyosis also have been diagnosed with Endometriosis in other sites outside the uterus, within the pelvis. As high as 62% of women who had hysterectomy were found to have this disease on pathology reports.
Adenomyosis presents in two different forms.
- The first type appears as solid tumors and are called Adenomyomas. This form of the disease is localized and is an encapsulated collection of endometrial cells with well defined borders. They appear much like fibroids and are often mistaken as such. Many can be safely removed from the uterus, but depending on size and location can the culprit of hysterectomy.
- The second, and more common type, is the diffuse disease that spreads out within the uterine myometrium. As the endometrial cells invade the organ, the uterus becomes enlarged and hardened, making pelvic exams and intercourse very painful. At the cellular level, the uterine muscle cells are being damaged as the disease spreads and eventually will lose their ability to stretch and contract. This is the main reason for the high rate of miscarriages during the 2nd and early 3rd trimester of pregnancy.
What Causes Adenomyosis.
At this point in research studies, the etiology or cause of Adenomyosis is unknown.
We do know that women diagnosed with Adenomyosis commonly have excess levels of the hormone estrogen…which encourages the disease to spread monthly.
A known genetic link is also present, as with endometriosis, and it does tend to run in family history. In my practice, I have also noticed an increase in the disease as an outcome of tubal ligations, and I have seen it in women who have reported both c-sections and pregnancy terminations (suction or curetting D&C). At this point, however, the reason for the disease continues to be inconclusive.
Adenomyosis Signs and Symptoms
The severity of the signs and symptoms associated with Adenomyosis is often directly
proportional to the degree of involvement and penetration into the uterine muscle. The more the disease spreads, the greater the symptoms. Many patients with Adenomyosis can be without symptoms (asymptomatic) just like fibroids and endometriosis, but most commonly women report the following symptoms associated with their enlarged uterus:
- Dysmenorrhea (painful periods)
- Hypermenorrhea (heavy periods)
- Prolonged bleeding cycles
- Large clots
- Abdominal bloating
- Back pain
- Severe and Increasing Abdominal pain throughout the month
- Painful Intercourse
- Nausea and Vomitting
Diagnosing and Detecting Adenomyosis
Obtaining a correct diagnosis of Adenomyosis can be very difficult. As a form of endometriosis, the disease is microscopic and can be hard to locate on diagnostic tests.
Many physicians will give a preliminary label of Adenomyosis based on signs and symptoms (listed above) reported by the patient at the time of pelvic exams. Since many symptoms are similar to fibroid tumors, Adenomyosis, especially the solid tumor type, is often mistaken for fibroids.
On occasion the disease is “suspected” via diagnostic tests. New higher technology ultrasound equipment is beginning to pick up changes to the uterine muscle and many radiologists will render a diagnosis.
The best noninvasive test is the MRI. When an MRI is ordered, a high intensity view of the uterine muscle will more clearly show the “damaged areas” within the myometrium, that will render a pretty good indication of a positive diagnosis.
The only true and conclusive test to diagnose Adenomyosis is a uterine muscle biopsy.
These can be problematic to obtain. A long needle can be placed into the uterus via laparoscopy or hysteroscopy and a tissue sample retrieved. However because this technique is a “blind approach” into the uterus, areas of biopsy are unseen and the pathology in question may be missed, hence rendering a incorrect or false negative result.
Many doctors are also concerned about performing this test due to the potential of bleeding.
Occasionally, during a D&C procedure where the lining of the uterus is sampled…for heavy bleeding, polyps or intracavity fibroids, tissue may be removed that will render a positive diagnosis of Adenomyosis.
In many cases, this is a difficult disease to conclusively diagnose. As mentioned previously, up to 62% of women find out they had the disease after hysterectomy, when tissue samples are fully evaluated via pathology.
Adenomyosis and Fertility
Adenomyosis is a very difficult disease to have when hoping for fertility.
Many patients will consult with their gynecologist for heavy bleeding, clots and significant monthly pain during and around periods. Most gyns will traditionally recommend a birth control pill and/or the “wait and see” philosophy. Eventually as the symptoms get worse they recommend a D&C, ablation therapy or ultimately a laparoscopy to determine the reason for the pain. Sadly, at this point, if Adenomyosis is suspected, the disease as often spread well into the uterus and the damage has been done.
Positive fertility outcomes are usually dependent upon how much of the uterus has been impacted by the disease. Many women can conceive with Adenomyosis, but due to the damage within the organ many pregnancies are lost via miscarriage. As Adenomyosis spreads into the myometrium of the uterus, monthly bleeding actually damages the individual uterine cells. These muscle cells over time lose their ability to stretch and contract. When a conception occurs and the fetus begins to the grow, the uterus can only stretch so far before it can no longer hold the pregnancy: this is when spontaneous miscarriage and/or uterine rupture occurs. As the disease spreads monthly, the damage becomes more extensive. This is the sole reason, that I strongly advise women, if you suspect you have Adenomyosis based on symptoms or a family history, or even a diagnosis with your healthcare provider, do not postpone your plans to have a family….act immediately whenever possible. The longer you wait , the less chance of a successful pregnancy outcome and maintaining future fertility options.
If you are pregnant and have been diagnosed with Adenomyosis, we recommend you consult with a high risk OB. Due to the nature of this disease and its potential damage to the uterus, uterine rupture is not uncommon. This is a life threatening condition, not only to the patient but also the fetus, and must be treated emergently.
Treatment of Adenomyosis
Traditional medicine will usually treat Adenomyosis in several ways: palliative therapy with pain meds and hormone manipulation, or minor outpatient procedures and ultimately hysterectomy.
- The first line of attack with most gynecologists is to treat symptoms. Many of the patients I have seen have been on a multitude of pain relievers and narcotics. Although this does nothing to directly treat the spreading Adenomyosis, it can and does give the woman some relief and some type of quality of life. Most women, in advance stages of the disease, have great difficulty performing even basic functions during the day, and these drugs can help give them some control over their life. My concern with this management, is the longer the Adenomyosis remains untreated, the more it is spreading into and damaging the uterus. Pain management can be a very slippery slope with a great sense of false security.
- Hormone manipulation in the form of birth control pills or progesterone therapy is also another relatively ineffective approach. Since most formulas contain estrogen in some dose, the pill is actually perpetuating the disease over time. In the short term, it may help regulate heavy bleeding and clotting in some patients, but the disease is still spreading into the uterus. Eventually the pills will become ineffective for symptom control, and at that point the Adenomyosis is well advanced.
- Progesterone therapy can help to balance the effects of excessive estrogen and has been known to slow down the aggressive progression of Adenomyosis. Some women can exhibit a reduction in the negative symptoms for a short period of time, however, this form of treatment is not always successful at mitigating symptoms once the disease is in advanced stages. It may be worth a try for a few short months, but ultimately surgical treatment usually cannot be avoided.
- Other minor surgical treatments like D&C and Ablation therapy (Novasure) can reduce bleeding and clotting, but have zero effect on the actual disease spreading in the uterus. Traditional gynecology often recommends these options to buy time before introducing the patient to the fact that they need major surgery. It’s a way to ease the patient into the reality that they need to have their uterus removed. Many patients have come to me, post ablation, seeing minimal change in their heavy bleeding and some report even more excruciating and agonizing pain with periods. The pain is likely associated with the fact that blood is now trapped in the myometrium with no way to be released since the lining has been burned away. Patients often cannot wait to have surgery for fear of another period with “pains similar to labor”. Both D&C and Ablation are both “bandaid” therapies that do not work long term for effective resolution of Adenomyosis.
- Finally, hysterectomy is the most common treatment for Adenomyosis. Its just easier, less stressful and safer for the patient to have a hysterectomy rather than lose major volumes of blood and potentially have significant post operative complications. Unfortunately, since most women are in their 30s and 40s when an irreversible hysterectomy is performed, a high percentage are left with major negative side effects for the remainder of their life. Please read our section of the Complications of hysterectomy. Our FAS procedure is an alternative option to having your uterus removed.
The Emotional and Psychological Effects of Adenomyosis
Much like Fibroid tumors, Adenomyosis produces physical, emotional and psychological challenges that can significantly effect a woman’s lifestyle. As symptoms progress, many patients begin to feel “trapped” without a way to escape this disease. More problematic
than the painful intercourse, lengthy periods, heavy bleeding and clots is the excruciating pain that often accompanies this diagnosis. Many women experience days of complete bed rest, nausea and vomiting and a life shattering inability to function, and this is happening on a monthly basis!! As I mentioned in the fibroid section, once a diagnosis is suspected, many women are relieved that they now have a name attached to their condition……they actually know what it is…..however once treatment options are discussed the sad and almost unreal nature of this disease hits home. Because the pain is so intense with many women, they do not want to postpone treatment for fear of going through another cycle of “labor pains” however when they find out that most treatments will render them infertile and/or completely remove their uterus women often become grief stricken and depressed. Even when fertility is no longer a consideration, many women are not psychologically prepared to part with their uterus. However, when fertility is a concern, the sad reality of this disease is that many women must give up their fertility hopes and dreams in order to have a positive quality of life. This can be the cruel nature of this disease.
How can Female Alternative Surgery help you???
Female Alternative Surgery (FAS) is a bloodless multidimensional procedure that uses vascular surgery principles, lasers and then uterine reconstruction to accomplish our goal of treating Adenomyosis. Our philosophy for all patients is to treat the disease, not just the symptoms. As we mentioned earlier, traditional gynecology all too often will use “bandaid” treatments like narcotics, birth control pills, D&C, and ablation therapy like the roller ball or Novasure procedure to treat the symptoms rendering an all too temporary false sense of security while in reality the Adenomyosis is uneffected and continues to spread. Treating the Adenomyosis from within the myometrium is the only effective and long term approach, short of hysterectomy, that will remove and resolve symptoms. With the help of vascular surgical techniques, lasers are employed to remove the core damaged area of the uterus that has been altered by the Adenomyosis, and then adjacent tissue is treated around that core to retard the spread.
Sadly, after this debulking procedure, this will remove fertility options for women. However, we feel it is of utmost importance that even when fertility cannot be spared the uterus remains, to perform its other paramount functions and allow the woman to progress holistically through the life cycle. Our FAS has safely treated Adenomyosis in hundreds of patients without hysterectomy and without blood transfusions. We are one of the very few advocates for women that recommend and perform a safe surgical option for the treatment of Adenomyosis without hysterectomy.
Remember: Every form of treatment should be tried before a hysterectomy is ever considered.
We can help you get your life back! If you are interested in our procedure, please visit the rest of our website for further information and/or contact us by filling in the form below.