Adenomyosis

Adenomyosis is a condition where tissue that normally lines the inside of the uterus grows into the muscular wall of the uterus, causing symptoms like heavy periods, severe cramping, and pelvic pain that can significantly affect daily life.

Table of contents

• What is adenomyosis?
• Signs and symptoms
• What causes adenomyosis?
• Who is at risk?
• How is adenomyosis diagnosed?
• Complications
• Treatment options
• Managing symptoms through lifestyle

• Uterus
• Endometrium
• Myometrium

What is adenomyosis?

Adenomyosis is a condition that affects the uterus, which is the hollow, pear-shaped organ where a baby grows during pregnancy. When someone has adenomyosis, the tissue that normally lines the inside of the uterus, called endometrial tissue, starts to grow into the muscle wall of the uterus. This muscle wall is called the myometrium^[1][2].

During a normal menstrual cycle, endometrial tissue thickens, breaks down, and bleeds. When endometrial tissue is present in the muscle wall of the uterus, it also thickens, breaks down, and bleeds. This process can make the uterus get bigger, sometimes doubling or even tripling in size. The condition can be painful, and periods can become heavy^[1][2].

Adenomyosis can be classified as diffuse, which means it involves a large area, or focal, where it affects a specific spot. Focal areas of adenomyosis surrounded by thickened muscle tissue are called adenomyomas^[4][13].

About one in three people with adenomyosis don’t have any signs or symptoms. Many people aren’t even aware they have the condition because it doesn’t always cause problems^[2][3].

Signs and symptoms

Some symptoms of adenomyosis affect your periods, while others can happen at any time during your menstrual cycle. The most common symptoms include^[1][2][3]:

• Heavy or long-lasting periods, sometimes with clots
• Painful periods, with severe cramping or sharp pelvic pain. The pain may be severe enough to stop you from doing your usual activities
• Pelvic pain that doesn’t go away, even when you’re not having your period
• Painful sex
• Bloating, heaviness, or fullness in your lower stomach area (sometimes called “adenomyosis belly”)
• A larger uterus, which might cause tenderness or pressure in the lower stomach area
• Difficulty getting pregnant

These symptoms tend to get worse over time if left untreated^[2].

What causes adenomyosis?

Experts aren’t sure exactly what causes adenomyosis, but researchers have several theories about how it develops^[1][2].

The most commonly accepted theory is that adenomyosis results from a disrupted boundary between the deepest layer of the endometrium and the underlying muscle layer. This disruption leads to inappropriate growth of endometrial tissue into the muscle wall, along with the growth of new small blood vessels and thickening of the adjacent muscle^[4].

Another theory suggests an embryonic mechanism, where certain stem cells that are present from birth undergo inappropriate development, leading to misplaced endometrial tissue. Evidence for this theory includes case reports of endometrial tissue found in women born without a normal uterus^[4].

Some research suggests that hormones, genetics, inflammation, or trauma to the uterus may contribute to adenomyosis. Data showing a higher occurrence of adenomyosis following procedures like cesarean section or dilation and curettage support the tissue injury theory^[2][4].

Who is at risk?

While the exact prevalence of adenomyosis is unknown, researchers estimate it affects between 20% and 35% of people with a uterus. Many cases go undiagnosed because not everyone has symptoms^[4].

Adenomyosis is more commonly diagnosed in certain groups of people^[2][3][6]:

• Women over the age of 30, particularly those between 40 and 50 years old
• People who have given birth at least once
• Those who have had prior uterine surgeries, such as uterine fibroid removal, cesarean delivery, or dilation and curettage
• People with endometriosis
• Those who started their periods at age 10 or earlier
• People with shorter-than-usual menstrual cycles
• Those who are obese

However, doctors are increasingly diagnosing adenomyosis in younger people in their 30s, and even in teenagers. Approximately 2% to 5% of adolescents with severely painful menstrual cycles have adenomyosis^[2][4].

How is adenomyosis diagnosed?

Diagnosing adenomyosis can be challenging because its symptoms are similar to other conditions affecting the uterus, including uterine fibroids, endometriosis, and endometrial polyps. Sometimes it’s hard for healthcare professionals to know for certain that someone has adenomyosis^[9][17].

Your doctor will start by asking about your symptoms, menstrual history, and family history. They may perform a pelvic exam, during which they can check whether your uterus has gotten larger, softer, or is painful to the touch^[2][3].

You can ask for a female doctor when you book your appointment. If the doctor needs to do an internal examination to check your vagina and cervix, you can have a friend, family member, or other member of staff in the room with you if you want^[3].

Several imaging tests can help confirm the diagnosis^[2][3][9]:

• Transvaginal ultrasound: This uses sound waves to create images of your pelvic organs. During this test, a narrow device is gently inserted into the vagina. These images can sometimes show thickening of your uterine wall
• Magnetic resonance imaging (MRI): This test can show uterine enlargement and thickening of certain areas of your uterus. It is particularly helpful in detecting signs of adenomyosis

If needed, your doctor may do an endometrial biopsy, where a small sample of tissue is removed and tested in a lab. This helps rule out more serious conditions, such as cancer, though it won’t confirm adenomyosis^[9].

The only way to be absolutely certain of a diagnosis of adenomyosis is to examine the uterus after a hysterectomy (removal of the uterus). However, this is not necessary for most people, as diagnosis can be made using the tests described above^[9][17].

Complications

The symptoms of adenomyosis tend to get worse over time if left untreated. Heavy menstrual bleeding increases the risk of anemia, which occurs when your body doesn’t have enough iron-rich red blood cells. Anemia may cause you to feel fatigued, weak, or cold^[2][6].

The constant pain and discomfort can also lead to emotional challenges, such as stress, anxiety, and depression, which can reduce quality of life. The condition may strain relationships and lead to social isolation, as people may avoid social events to better manage their symptoms^[5].

Some research suggests that adenomyosis may make it harder to get pregnant and may increase the risk of miscarriage. The condition may affect pregnancy by changing the shape of the uterine cavity, causing inflammation, causing unusual uterine contractions, or changing hormones important to pregnancy^[6][7].

It’s important to know that adenomyosis itself doesn’t cause cancer or lead to cancer. It is a benign (non-cancerous) condition^[2].

Treatment options

While there is no definitive cure for adenomyosis other than removal of the uterus, symptoms often go away after menopause when hormone levels decline. Treatment focuses on managing symptoms and depends on your individual circumstances, including the severity of your symptoms, your age, and whether you plan to become pregnant in the future^[1][2][9].

Pain medications

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, can help ease cramping and reduce pain. These medications work by blocking the production of substances called prostaglandins, which contribute to pain and inflammation. They are most effective when taken at the onset of symptoms or a few days before your period begins^[2][9][14].

Hormonal treatments

Because the hormone estrogen promotes endometrial tissue growth, hormonal treatments aim to regulate or suppress hormone levels. Options include^[2][9][14]:

• The intrauterine system (IUS), also called Mirena or hormonal coil, which releases progesterone to thin the uterine lining, making periods lighter and less painful
• Other types of hormonal contraception, such as the progestogen-only pill, the combined pill, or the contraceptive patch
• Progesterone shots or tablets to limit tissue growth and relieve pain
• Gonadotropin-releasing hormone (GnRH) agonists, which can stop menstrual cycles and reduce the size of adenomyotic tissue. However, these are typically used short-term because they can cause menopause-like side effects such as bone density loss

While hormonal therapy can be effective, symptoms often return after treatment ends, making it a temporary solution for many people^[6].

Other medications

Tranexamic acid is a non-hormonal medication that helps reduce heavy menstrual bleeding by promoting blood clotting. It is taken during menstruation and is particularly helpful for people experiencing excessive blood loss^[14][16].

If you have anemia caused by heavy bleeding, iron supplements can help restore your energy levels and overall health^[16].

Minimally invasive procedures

For people who do not respond to medications or hormone therapy, several minimally invasive procedures may offer longer-term relief^[13]:

• Uterine artery embolization: This procedure reduces blood flow to the uterus, causing the adenomyotic tissue to shrink. It has been shown to significantly improve symptoms like heavy bleeding, pain, and urinary frequency
• High-intensity focused ultrasound (HIFU): This method uses targeted ultrasound beams to cause thermal ablation and destruction of adenomyotic tissue, allowing patients to preserve their uterus
• Endometrial ablation: This procedure removes the uterine lining to reduce heavy bleeding. It is not suitable for people who wish to preserve fertility

Surgical options

Surgery may be considered in severe cases where other treatments are not effective^[3][9][14]:

• Adenomyomectomy: This procedure removes focal areas of adenomyosis (adenomyomas) while preserving the uterus. It may be an option for people who want to maintain their ability to become pregnant
• Hysterectomy: Removal of the uterus is the only definitive cure for adenomyosis. This is typically considered as a last resort for people who have completed childbearing and have severe symptoms that don’t respond to other treatments

Managing symptoms through lifestyle

In addition to medical treatments, lifestyle changes can play an important role in managing adenomyosis symptoms and improving overall well-being^[15][19].

Self-care for pain relief

There are several things you can do at home to help with period pain or pelvic pain^[3][14]:

• Use a heat pad or hot water bottle wrapped in a tea towel on your lower stomach
• Try a TENS machine, which is a small device that uses mild electrical impulses to reduce pain
• Take painkillers like paracetamol or ibuprofen as directed

Diet and nutrition

What you eat can have a significant impact on inflammation and hormone regulation. An anti-inflammatory diet focuses on whole, nutrient-dense foods^[16][19]:

• Fill your plate with fresh vegetables, especially dark leafy greens, broccoli, cauliflower, and capsicums. These vegetables help balance estrogen levels
• Include fruits, particularly berries and citrus fruits, which are rich in antioxidants
• Eat fatty fish like salmon, mackerel, sardines, and anchovies, which are high in omega-3 fatty acids that reduce inflammation
• Choose whole grains over processed foods
• Include nuts (especially Brazil nuts which are high in selenium) and avocados
• Use herbs and spices, both dried and fresh, for their anti-inflammatory properties
• Drink green tea, which is rich in beneficial compounds called catechins

It’s important to note that while some sources suggest avoiding certain foods, you don’t need to completely eliminate any food group. The focus should be on adding more nutritious foods rather than restricting yourself^[19].

Exercise and stress management

Regular low-impact activities like walking, swimming, or yoga can improve circulation, reduce stress, and help alleviate pelvic discomfort. It’s important to consult your doctor before starting a new exercise program^[5].

Stress can make symptoms worse, so practicing stress-reduction techniques such as meditation, deep breathing exercises, or mindfulness can promote relaxation and emotional well-being^[5].

Tracking symptoms

Maintaining a symptom diary can be very helpful. Record your pain levels, menstrual cycles, and any triggers you notice. This information provides valuable insights for both you and your healthcare team and can help guide treatment decisions^[5].

When to see a doctor

You should see a healthcare professional if^[1][3]:

• You have heavy periods that last a long time
• You have severe cramping during your periods that interferes with your daily activities
• Your periods become more painful, heavier, or irregular
• You have pain during sex
• You’ve been feeling bloated for about 3 weeks
• You bleed between periods or after sex

Seek urgent medical help if your pelvic pain or period pain is severe or worse than usual, and painkillers have not helped^[3].