Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus. This benign invasion of the middle layer of the uterine wall has been described as a variant of endometriosis – and although the conditions can occur together, they are distinct diagnoses. The main symptoms of adenomyosis are menorrhagia ( heavy menstrual flow ) and dysmenorrhoea ( pain during periods ), and it frequently occurs together with fibroids. Adenomyosis may be seen after the surgical interventions like :

1. Pregnancy and childbirth
2. Caesarean section
3. Uterine surgery (e.g endometrial curettage)
4. Surgical management of miscarriage or termination of pregnancy

Clinical Features

The main presenting symptoms of adenomyosis include menorrhagia, dysmenorrhoea, deep dyspareunia and irregular bleeding (10-12%). The dysmenorrhoea is commonly progressive; beginning as cyclical pain, but can worsen to daily pain. On examination (abdominal and bimanual palpation), a symmetrically enlarged tender uterus may be palpable.

Investigations

Transvaginal ultrasound

MRI

Management

The main aim in the management of adenomyosis is to control the dysmenorrhoea and menorrhagia.It is most often resistant to medical management. Currently the only curative therapy is hysterectomy. NSAIDS are used for analgesia, and hormonal therapy for reduction of bleeding and cycle control.

Hormone Therapy

The available hormonal therapies include:

Combined oral contraceptives

Progestogens (oral or Intrauterine system e.g. Mirena)

Gonadotropin-releasing hormone agonists

Aromatase inhibitors.

Continuous combined oral contraception and high dose progestins (e.g. subcutaneous depot medroxyprogesterone) have been seen to temporarily induce regression of adenomyosis.

Summary

1. Adenomyosis is the presence of functional endometrial tissue within the myometrium of the uterus.
2. It causes dysmenorrhoea and menorrhagia.
3. Likely caused by anything disrupting the uterine lining allowing the endometrium to invade the myometrium e.g. pregnancy, uterine surgery.
4. Seen towards the end of the reproductive years.
5. Difficult to diagnose with imaging, histology at hysterectomy definitive.
6. Treatment conservatively with analgesia and hormone control of cycle.
7. Only curative treatment is hysterectomy.