Adenomyosis Fact Sheet 3w594t

FERTILITY TREATMENT CENTRE

ADENOMYOSIS FACT SHEET Adenomyosis was first described in 1860 but it was not until 1972 that it was clearly defined. The condition is characterised by endometrium invading the muscle wall or myometrium of the uterus, leading to enlargement of the uterus. When observed down a microscope, adenomyosis can be seen to contain glands which are the same as the endometrial lining of the uterus. The subject of adenomyosis has recently been reviewed by Garcia L and Isaacson K; the Journal of Minimally Invasive Gynaecology 2011; vol 18 number 4 July/August 2011. Dr Isaacson is well known in the fertility world. Previously, the only way that adenomyosis could be confidently diagnosed was by pathological examination on the uterus following on from a hysterectomy operation. In recent years, Magnetic Resonance Imaging (MRI) has proven to be particularly useful as a diagnostic screening tool for adenomyosis. This will lead to a complete re-evaluation of our understanding of this condition and in time, more information will come to light regarding its link with miscarriage and infertility. This in turn will lead to more clearly defined pathways for medical treatment and conservative surgical treatment for this condition. What causes adenomyosis? We are not entirely sure what causes adenomyosis, but the most likely explanation is that for reasons which are unclear, the endometrium starts to invade the myometrium. A second theory is that when the uterus is forming in utero, some parts of the myometrium contain endometrial tissue which only becomes active later in life. The third theory is that endometrial cells spread into the myometrium through the lymphatic system. A fourth theory is that stem cells from the bone marrow become deposited in the myometrium and develop into endometrial-like tissue. Presentation of adenomyosis The typical symptoms of adenomyosis are heavy periods (menorrhagia) and painful periods (dysmenorrhoea). Other symptoms include painful intercourse (dyspareunia) and chronic pelvic pain. Infertility is a less common symptom, but with more women delaying child-bearing until their 30’s, adenomyosis is now being seen more frequently. PI.GEN.0029

Adenomyosis

Page 1 of 4

Implemented January 2012

Approved by Mr Booker and s Stevens

Version 1 Next Review 01.2013

Diagnosis On clinical examination the uterus may be enlarged and this may be evident on transvaginal ultrasound, hysteroscopy and laparoscopy. At hysteroscopy, sometimes ‘pitting’ of the endometrium is seen. Transvaginal ultrasound can show areas of diffuse enlargement of the uterus, similar to fibroids. Although adenomyosis can be suspected on ultrasound, it is not sufficiently sensitive or specific for this condition. In particular, it is not possible to confidently discriminate between uterine fibroids and adenomyosis on ultrasound scanning. If adenomyosis forms a discreet mass within the uterus, this is known as an adenomyoma. Of all the diagnostic techniques, MRI scanning is the most accurate for diagnosing adenomyosis, particularly with the T2-weighted images. The junctional zone between the endometrium and myometrium can be seen to be markedly thickened. How common is adenomyosis? The answer to this is that we just do not know. This is because until recently, the only way adenomyosis could be confidently diagnosed, was at the time of hysterectomy. About three quarters of women with adenomyosis are aged between 40 and 60 years and a quarter are younger than 40. Estimates about the prevalence of adenomyosis vary between 5 – 70%. Overall, it is more common in women who have had a pregnancy. Treatment Surgery - The main treatment for women over 40 who have been diagnosed with adenomyosis has, until recently, been hysterectomy. However, with the move away from hysterectomy, conservative treatments are now being considered more frequently. For women not wishing to preserve child-bearing function hysterectomy is curative for treating adenomyosis. The oral contraceptive pill and cyclical progestogens can ease symptoms, but typically are only suitable for temporary use. The Mirena IUS has increasingly been shown as suitable for treating adenomyosis and often women will be sufficiently improved and will not want to contemplate any further treatment, particularly hysterectomy. Danazol was popular for treating endometriosis between the early 70’s and the early 90’s but its use has declined because new treatments came in and also Danazol tended to produce unpleasant side effects. However, it remains an option for treating women with adenomyosis. New techniques are being developed to try and deliver Danazol locally to the uterus, through intracervical injections and also an intrauterine device. This is still at the research stage. PI.GEN.0029

Adenomyosis

Page 2 of 4

Implemented January 2012

Approved by Mr Booker and s Stevens

Version 1 Next Review 01.2013

Gonadotrophin releasing hormone agonists, such as Danazol and Prostap SR, will treat the symptoms of adenomyosis effectively, but typically are only suitable for short-term use (up to 6-months). Endometrial ablation and resection are surgical techniques which can be successful in either stopping the periods completely or reducing the heaviness of periods. However, for patients with adenomyosis, this technique is less effective for treating pain and, in this situation, hysterectomy may be required. Uterine artery embolisation has been used for treating adenomyosis. At present, the published numbers in the medical literature are small, with around half the patients treated experience a satisfactory response. However, in these studies, many of the patients went on to require hysterectomy as the failure rate with this technique was undoubtedly quite high. The largest study showed a patient satisfaction rate of 70%. Surgical excision has been used to treat adenomyosis. If the adenomyosis is in a discreet mass, called an adenomyoma, then it is possible to remove this in much the same way as uterine fibroids are removed. Typically however, with adenomyosis, the disease is more diffuse making conservative surgical treatment more difficult.

Additional Comments by Michael Booker In 2008 I attended the annual American Society of Reproductive Medicine in San Francisco. There was a presentation at this meeting by Dr Sherman Silber from St Louis, Missouri and Dr Osada from Japan. They presented the Osada Technique for adenomyomectomy. This is a novel technique involving a triple flap procedure for removing the adenomyosis tissue and repairing the uterus. I have since performed the Osada Technique when operating on a number of patients and have been impressed with how well the technique works and also impressed with the outcome for the patient. A patient of mine, Mrs YA aged 42, presented with a 10-year history of heavy periods, ing large clots and severe pain. She had seen at least two other consultants before she came to see me. Ultrasound scans had suggested adenomyosis and a subsequent MRI scan showed a large adenomyoma. The MRI scan showed a large adenomyoma in the posterior wall of the uterus. The patient underwent the Osada Technique operation in October 2010. The procedure was straightforward with no complications.

PI.GEN.0029

Adenomyosis

Page 3 of 4

Implemented January 2012

Approved by Mr Booker and s Stevens

Version 1 Next Review 01.2013

I saw her for review in June 2011. She was back to normal periods and an ultrasound scan showed that the uterus looked perfectly normal. I was able to discharge her back to the care of her GP. In October 2011 I attended the annual meeting of the American Society of Reproductive Medicine in Orlando, Florida. I attended a Round Table discussion group about adenomyosis. The consensus of the group was that the Mirena IUS is a good first-line approach for patients with adenomyosis and, if the uterus is enlarged, it helps to fit the Mirena IUS under ultrasound guidance. We discussed whether or not adenomyosis is a cause for infertility and whether or not adenomyosis is a cause for miscarriage. The consensus of the group was that adenomyosis is a cause for miscarriage and infertility, in much the same way that uterine fibroids can be a cause for miscarriage and infertility. We also discussed the Osada Technique operation and the view was that this is an effective way for treating patients who have a discreet adenomyoma.

Reference Osada H, Silber S et al. Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis. Reproductive Biomedicine Online, September 2010

PI.GEN.0029

Adenomyosis

Page 4 of 4

Implemented January 2012

Approved by Mr Booker and s Stevens

Version 1 Next Review 01.2013