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Adenomyosis
This information summarizes what adenomyosis is, the main signs and symptoms and
current ways of managing it. It is intended for those who may have adenomyosis.
What is it?
Adenomyosis is defined by the finding of endometrium (the tissue that normally lines the
inside of the uterus/womb) within the myometrium (muscular wall of the womb). The cause is
not known, although there are several theories. One theory is that it has a hormonal origin,
another is that it may be due to disruption of the myometrium. Adenomyosis can be found in
women of all ages, including adolescents.
What symptoms are associated with adenomyosis?
Women with adenomyosis often have particularly painful and/or heavy periods (Pepas, L. et
al, 2012). However, women with adenomyosis may have no symptoms.
How is it diagnosed?
Adenomyosis can be difficult to diagnose but increasingly ultrasound and MRI are being
used. With transvaginal ultrasound, considerable training is needed to recognize the
ultrasound pattern in the diagnosis of adenomyosis. With MRI, the findings are less
dependent on the person doing the scan, but still depends on an observer who is expert in
reporting such scans in gynaecology (Dueholm 2007). A review comparing the accuracy of
diagnosis for ultrasound and MRI showed that a correct diagnosis was obtained more often
with MRI (Champaneria 2010). Adenomyosis can be easily confused with fibroids with both
ultrasound and MRI. You may want to ask to be referred to someone who is experienced in
recognizing and identifying adenomyosis in imaging/radiology. Adenomyosis may be a
reason for continuing pain following surgery for endometriosis.
How is it treated?
Medical treatment for adenomyosis-associated pain includes anti-inflammatory medications
and hormone therapy such as GnRH agonists (e.g. Zoladex and Decapetyl) or
levonorgestrel-releasing intrauterine devices (LNG-IUD e.g. Mirena). A study investigating
the long-term effects of a LNG-IUD concluded that it helped with relief of symptoms for up to
two years, after which time its efficacy decreased (Cho 2008).
Uterine Artery Embolisation (UAE) may be an option. However, NICE encourages further
research into the effects of UAE compared with other procedures to treat adenomyosis,
particularly for patients wishing to maintain or improve their fertility (NICE IPG 473). UAE
involves injecting small particles into the blood vessels that take blood to the uterus, via
arteries in the groin. The aim is to block the blood supply to the adenomyosis so that it
shrinks, which may then relieve the symptoms. During the consent process, patients should
be informed that symptoms may not be relieved, that symptoms may return and that further
procedures may be needed. Patients contemplating pregnancy should be informed that the
effects of the procedure on fertility are uncertain.
In the last few years, there have been several studies using high intensity focused
ultrasound (HIFU) ablation therapy for adenomyosis, with up to two years follow-up. All of
the studies conclude that this therapy may be a safe and effective non-invasive alternative to
treat adenomyosis (Wang 2009, Zhou 2011, Zhang 2013). The study by Wang suggested
that the severity of symptoms correlates with the extent of adenomyosis, and that ablating
sufficient volume of adenomyosis may provide greater pain relief
Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is being used in a few
small studies for those with focal adenomyosis. These studies suggest that clinical
improvement in symptomatic adenomyosis is achievable within a short period of time after
treatment with MRgFUS. MRgFUS is a non-invasive, day-care procedure, requiring no
admission, and having a low complication rate (Kim 2011, Fan 2012 ). MRgFUS may be a
promising alternative to hysterectomy for the patient with adenomyosis who wishes to
preserve her uterus. A number of reports of successful treatment have been published that
also show the feasibility of pregnancy following MRgFUS.
To our knowledge HIFU and MRgFUS are not performed for adenomyosis in the UK,
although the latter is carried out in some cases for fibroids.
There have been a few non-randomized studies of conservative surgery, termed
‘adenomyomectomy’ (excision of the adenomyosis) suggesting that this may relieve
symptoms while conserving the uterus (Takeuchi 2006, Sun 2011). One study (Wang 2009 )
concluded that surgical and medical treatment (GnRH agonist ) combined gave a lower
symptom-relapse rate than surgery alone during the two year follow up period.
Adenomyomectomy is an advanced surgical procedure and in our opinion patients
considering such a procedure should ask about the experience and outcomes of the surgeon
(Pepas 2012). There may be a role for hysteroscopic endometrial resection or ablation if the
adenomyosis is superficial, involving less than 3 mm of the myometrium.
Patients would like to see greater accuracy in diagnosis of adenomyosis and increased
efforts to offer alternatives to hysterectomy, which has been the conventional surgical
treatment. Patients comment that they would welcome information about alternatives during
consultations, and that links to websites should be readily available to them to assist in
decision making.
References and further reading:
Champaneria, R., Abedin. P., Daniels, J., Balogun, M., Khan, K.S. Ultrasound scan and
magnetic resonance imaging for the diagnosis of adenomyosis: systematic review
comparing test accuracy. Acta Obstetricia et Gynecologica Scandinavica 2010
Cho S. Nam A. Kim H. Chay D. Park K. Cho DJ. Park Y. Lee B Clinical effects of the
levonorgestrel-releasing intrauterine device in patients with adenomyosis . American Journal
of Obstetrics & Gynecology. 198(4):373.e1-7, 2008
Pepas, L., Deguara. C, Davis, C., Update on the surgical management of adenomyosis
Curr Opin Obstet Gynecol. August 2012
http://guidance.nice.org.uk/IPG473/Overview/pdf/English
PPSN-WEB-012
Issue date: February 2014
Review date: February 2017