Adenomyosis Q & A
Dr Graham Tronc, Graham Tronc Medical
It's a disease with even less name recognition than endometriosis, but it can cause similarly debilitating symptoms and issues with fertility. Adenomyosis occurs in many women who already have endometriosis, and can often be the cause of persistent pain and symptoms in women where no endometriosis was found at laparoscopy. It's a condition more and more women are beginning to ask questions about, and at QENDO we're here to help.
Dr Graham Tronc, obstetrician and gynaecologist with a special interest in early diagnosis and treatment of endometriosis and adenomyosis, has answered some of our most frequently asked questions about adenomyosis.
What is adenomyosis and how is it different to endometriosis?
Adenomyosis is a disease where the endometrium grows into the muscle of the uterus. The patient then suffers numerous microscopic bleeds in the muscle, at the time of the period.
What are the symptoms of adenomyosis?
The symptoms of Adenomyosis are often very similar to Endometriosis, with heavy, painful periods being the most common. Added symptoms include referred pain to the back and down the legs, with general associated feelings of fatigue. The pain can be at least as bad as Endometriosis, sometimes worse, because the patient doesn’t yet have a diagnosis.
When should one consider looking into a diagnosis of adenomyosis?
Because generations of gynaecologists have all been taught and are STILL being taught, that adenomyosis is a disease of the third and fourth decade, it is often missed at laparoscopy done for Endometriosis. I always consider the possibility of “Adeno” when I laparoscope patients because the two conditions can co-exist. Indeed, the “age” rule is a myth. I personally have over 30 patients (unpublished data) who are less than twenty (20) years of age with MRI proven Adenomyosis and that is just one gynaecologist. Food for thought!
As outlined above, I listen out for symptoms of back pain and pain down the legs. At laparoscopy, I look for several things when considering whether the patient may have adenomyosis. The uterus is usually bigger (not necessarily so in the very young patient). The uterus tends to be softer and “indent” easily when instruments are pushed against the uterus. There may be a “bumpy” outline to the surface of the uterus (this is subtle). Finally, where the tube attaches to the uterus, there may be a thickening. This makes this area look white.
I have not seen it described in the literature, but call it “TRONC’S TUBAL SIGN”.
At hysteroscopy, I often note small longitudinal lines, or grooves at the top (fundus) of the uterus. In severe cases, there can be “holes” very similar in appearance to where the fallopian tubes exit the uterus.
If I see these signs, OR if I find no signs of Endometriosis (as suspected pre-operatively), I then ask for an MRI scan. An MRI measures the thickness of the “junctional zone” which is the junction of the ENDOMETRIUM (lining) and the “myometrium” muscle. This distance should be less than 5mm. More than 12mm confirms the diagnosis. In between 5 and 12mm, especially in a young woman means it is probably still developing.
However, 80% only of cases are diagnosable by MRI. If the MRI is negative but I am still convinced of the diagnosis, I THEN ask 1 or 2 specialist Ultrasonographers to look for ultrasound signs of Adenomyosis. But in my mind MRI is still the diagnostic tool of choice. At the Wesley Hospital an MRI of the uterus costs $350 approximately and takes 45 minutes to perform.
How is it diagnosed? How do I find someone who knows what they are looking for?
Adenomyosis should always be suspected when:
Endometriosis is found; or
When no endometriosis is found when symptoms have suggested it. An experienced eye is needed. Specialists who frequently deal with Endometriosis are (in my opinion) more likely to “find” it at laparoscopy. Steer clear of Doctors (even specialists) who still regard Adenomyosis as a disease of the late 30’s and 40’s, and especially those who say “you couldn’t possibly have adenomyosis, you are too young".
You can find out more about the diagnosis of adeno via MRI here
What treatments are available for adenomyosis? Does it mean more surgery?
The diagnosis of Adenomyosis, once made, does NOT necessarily mean any more cuts on the abdomen (laparoscopies). However, because Adenomyosis often co-exists with endo, further laparoscopies may be needed, and I suggest a brief general anaesthetic to put in a Mirena (or 2 Mirenas).
I personally OFTEN suggest Combination Medical treatment for Adenomyosis. Common combinations include not 1, but 2 Mirenas, in combination with the Pill, used continuously (no breaks or sugar pills); 2 Mirenas and high dose progesterone, and sometimes 2 Mirenas and Zoladex (a GnRH analogue). Certainly in a patient who is young, and not had babies and wishes to (usually obviously) conserve her fertility, it is better to get on top of Adenomyosis early. Like Endometriosis, the worse the Adenomyosis is before treatment begins, the harder it is to treat.
I am already receiving treatment for my Endometriosis, I think maybe I also have Adenomyosis … will a diagnosis of adeno change my treatment? Is a diagnosis worth pursuing?
If you already have a diagnosis of Endometriosis, yet you still have pain, there are really only about three reasons: Endometriosis has been insufficiently treated; there are adhesions present from Endo, or previous surgery, or adenomyosis itself.
I always ask for the patient’s previous surgical photos in an attempt to clarify the diagnosis.
The next thing that is needed is an MRI before any more surgery!
How does Adenomyosis affect fertility?
Adenomyosis can certainly affect fertility. It can cause subfertility (delay); recurrent miscarriages, premature labour and premature rupture of the membranes.
There are several articles in Australian awareness literature that address this issue.
I hope this has been of some help to you.
Dr Graham Tronc
(Gynaecologist; Founder of the Brisbane Endometriosis Clinic)
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