Answer from: Luciano Nardo, MD, MRCOG
Adenomyosis, if we can perhaps describe it as a part of the same family as the endometriosis but the difference between the endometriosis and the adenomyosis is simple: the endometriosis is the lining of the womb (so the endometrial tissue that grows outside the uterus and involve other organs). In the case of adenomyosis, the endometrial tissue goes into the muscle of the uterus so in the middle layer of the uterus. Women that have got adenomyosis may have the same symptoms as women that have endometriosis and some women have got endometriosis may also have adenomyosis. Usually symptoms of painful intercourse, pelvic pain, heavy periods, painful periods and sometimes make the diagnosis of adenomyosis or endometriosis one that has to be clinically differentiated. From a diagnostic perspective, adenomyosis can be seen in most cases by a transvaginal ultrasound scan which obviously helps in making that final diagnosis and the treatment of adenomyosis, in most cases, is a hormonal treatment by creating that temporary menopause that stops the flare up of the endometrial tissue into the muscle of the uterus. Adenomyosis has been associated with infertility and has also been associated with implantation failure after IVF treatment.
Pain medications, again, pain relief can be prescribed the steroidal anti-inflammatory drugs, can be prescribed the pill and women who have completed the family, have decided to not have more children, they may end up having a hysterectomy.
Answer from: Sibte Hassan, MBBS, FCPS, MRCOG, MSc
Adenomyosis is basically a thickening in the womb muscle wall. What happens is, normally in the menstruation the lining of the womb sheds and it comes out whereas if somebody has developed adenomyosis, this lining somehow goes into the muscle wall of the womb and it stays there. Then it responds to hormones as well every month. The symptoms it leads to are painful periods and heavy periods. It is related to infertility in some ways. These patients are slightly at risk of infertility as well. The main treatment depends upon the symptoms so, if there is heavy bleeding or pain, you can have pain control and you can control the bleeding with medical treatment. Obviously if it is related to infertility and the patient wants to ameliorate that symptom, obviously, we assess the other factors related to fertility as well because it’s difficult to associate only adenomyosis with fertility. Usually adenomyosis happens in a slightly older age group compared to the other similar sort of pathology which is endometriosis which is a relatively younger age group, adenomyosis is in a slightly older age group. If fertility is a concern in such patients then obviously we evaluate the other factors as well and obviously assisted conception is always available for these patients.
Answer from: Ahmed Elgheriany, MRCOG, MD, MSc
Adenomyosis it’s happening when the lining of the womb instead of migrating outside and forming endometriosis into outside the womb, this lining of the womb migrating inside the womb muscle itself. So you will have to menstruate from the natural way and to have menstruation inside the muscle of the womb. It’s a very problematic disease, it’s a very devastating problem and causes chronic pelvic pain for a long time for many ladies. Up until now, the only treatment for this after giving hormonal medication and wait for the hormone effect on the body, like mirena coil insertion into the womb, to decrease this storm a little bit but if not effective so some women may have surgery and they come into the problem with surgery and endometriosis and the fertility. So, if she has an adenomyosis and she is looking for a baby, it’s very problematic. This is the problem with adenomyosis until now. A very recent Chinese study about a recent treatment for adenomyosis it’s done by something called a high frequency ultrasonography. It’s a high frequency ultrasonography. Basically women will lie flat on a scan machine and that’s ascending like a scan out of 2d scans that you are doing but with a very high frequency concentrated rays that will hit only the adenomyosis gland. This is applied now in China. It’s a very primitive study. What was done on over three thousand ladies and the side effect from it it’s comparable to the side effect from the hormonal treatment (either it’s mirena coil, either it’s injection to stop the hormones in your body) and have menopausal symptoms and preventing women from having hysterectomy. So this treatment is very primitive and it’s very very new. We need small research about it but it’s effective in cases of adenomyosis.
Answer from: Anu Chawla, MRCOG, MBBS, M.S., DNB
It can be a very challenging situation for both patient and the doctor to be in. Adenomyosis can affect the implantation and the carrying and the maintaining of the pregnancy and it can be the reason for the repeated negative tests so that the implantation is not happening so, it can be the cause of the recurrent implantation failure or the recurrent IVF failure – both. Adenomyosis also can be very symptomatic meaning that because a uterus is very congested and it can be seen in the ultrasound for real, that these patients might have a lower quality of life in this sense that the pain can be so bad that sometimes they can’t go to work. Adenomyosis is basically the muscle of the uterus having the glands and these glands are active during periods and that causes pain and the congestion and the circulation of that area is higher. Obviously the nature of the problem is it’s an inflammatory basis of the pathology so, that is an independent cause of pain. It can be very symptomatic and the treatment is difficult because there is no capsule around adenomyosis unlike the fibroid. Taking out the fibroid is relatively very easy as compared to correcting the adenomyosis but I have seen because of various reasons maybe the operating surgeon is not trained enough or doesn’t feel confident enough but removing or not removing adenomyosis first of all this decision and then, if at all it is to be removed, who does that. These are two important independent things. So, whether this adenomyosis is supposed to be left in the body or it is supposed to be removed – is the first decision which is to be made very carefully and then if it is to be done, it should be done in the right hands, can really do it properly without damaging the uterus. We do not have studies but in the silver cases, removing the adenomyosis might give a better outcome. Another way how adenomyosis can be treated before the IVF is by giving the depo lupron injections are. It basically calms down the whole reproductive organs. In that process, it comes down the adenomyosis on the functional aspect also so, everything has one physical aspect of just the mere presence and then the functional aspect, the biochemical aspect so, at least that aspect is taken care of by giving this depo injection which is given once a month sometimes one or two or up to three months before the actual IVF is done. This injection will calm down the whole reproductive system and it improves the outcome in a rightly selected group of women. In cases of adenomyosis, I try to give the injection crosstab at least once before the IVF and also before the frozen embryo transfer, if we have the frozen embryos for this patient. This overall anti-inflammatory effect of this injection might help although it is not in the protocol for many units because the evidence is not enough yet but these are the two methods medical and the surgical for adenomyosis but it can be a massive challenge for the doctor as well as the patient because if at all the adenomyosis is pretty significant and the previous implantations have failed, then removing the adenomyosis in safe hands might help but this is an important and careful decision after proper discussion, with the discussion of the side effects or the complications involved because we are actually taking out the adrenal meiosis and re-stitch the uterus so, it needs time to heal back and it can be more traumatic in untrained hands because it doesn’t have a clear capsule so, the expertise of the surgeon becomes very crucial.
Answer from: Andrew Horne, Professor
Adenomyosis is when you get tissue like the lining of the womb in the muscle of the wall of the womb, so it’s a little bit like endometriosis. The treatments for adenomyosis are not dissimilar to those for endometriosis except surgery isn’t really an option because of where it lies, because you’d have to remove the womb itself and obviously that’s not a treatment for people who are trying to get pregnant. The alternative treatments for adenomyosis largely are around managing the pain that’s often associated with it and so these are hormone treatments or even simple analgesics like non-steroidal anti-inflammatory drugs.
Answer from: Shamma Al-Inizi, FRCOG
It can exist by itself and can be associated with endometriosis it’s when the lining of the womb which is the gland stroma is present in the muscle of the womb so, the lining is away from its place and it’s in the muscle of the womb making the womb to be bulky and tender. Ladies usually present with pelvic pain which is chronic usually and also pain during periods and pain with intercourse quite similar to endometriosis, they also have abnormal vaginal bleeding and heavy periods and it might affect fertility as well. Yes, so it’s not easy to treat adenomyosis, slightly different to endometriosis because don’t forget the lesion is in the womb itself of course, the gold standard for treating first to diagnose adenomyosis we suspected clinically according to what the lady tells us (chronic pelvic pain and painful periods, painful intercourse, abnormal vaginal bleeding) we examine the lady, it’s a tender bulky womb, we confirm the diagnosis by an ultrasound scan and sometimes we need to do an MRI scan and to treat it the goal standard if the lady has completed her family is removal of the womb structure but of course if you are talking about a woman in the context of trying for a baby, it’s a fertility, the treatment, if she’s trying for a baby we cannot give her the same hormonal therapy which we explained for endometriosis which is exactly the same: the progesterone pill, the mirena coil which has produced a progestational coil, the dopo propellor injection, the implant and zoladex which is the gonadotropin releasing hormone and it will stop the ovaries from working. The same medications which we offer for ladies with endometriosis, we offer for adenomyosis but if the lady is trying for a baby, it can’t reduce the chances of implantation which we said but if the adenomas is quite extensive sometimes we offer a surgical treatment, surgical excision of the adenomyosis. This can be done laparoscopically and can be done openly. It is not a straightforward operation, is not performed in all hospitals but it can be done and the lesion of adenomyosis will be excised and the wound will be switched back and there is slight increased risk of rupture uterus of course if the lady is trying for a baby later on but according to some data published that it can improve pelvic pain and can improve fertility.
How can adenomyosis be treated?
Most experts share the opinion that the best way to treat adenomyosis is with a hysteroscopy and it is a case of surgical removal of the uterus. Is that the only option? Are there any alternatives to surgery?
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