If you’ve ever gone to your general practitioner or OB/GYN with heavy bleeding, pain during sex, or spotting between periods, chances are good that you’ll be worked up to rule out adenomyosis as the cause of your symptoms. But what is adenomyosis? How do you know you have it, and if you do, how do you treat it?
Adenomyosis vs. endometriosis
Adenomyosis occurs when endometrial tissue (tissue that would normally line the inside of the uterus) grows down into the muscle layer of the uterus. Adenomyosis is different from but can exist concurrently with endometriosis, which is the growth of endometrial tissue outside the uterus, whether on the outside of the uterus or on another pelvic or abdominal organ [1].
Like normal endometrial tissue, adenomyosis responds to cyclical hormonal fluctuations by thickening, breaking down, and shedding or bleeding over the course of the menstrual cycle. Because the tissue is in the wrong place, however, significant pain and abnormal bleeding patterns can result. The causes of adenomyosis are not well understood, though several theories as to why it develops are here. One established fact is that adenomyosis is aggravated by estrogen.
What are the symptoms of adenomyosis, and how is it diagnosed?
About one-third of women with adenomyosis do not experience any symptoms. Severity of symptoms varies for the other seventy percent of women with the disease.
Symptoms may include:
- Heavy periods
- Severe pain or cramping during periods
- Pain with sex
- Bloating, tenderness, or pressure in your stomach region
- Prolonged bleeding
- Passing blood clots on your period
- Spotting or bleeding when you’re not on your period
- Chronic pelvic pain
- Bleeding in between periods
- Swelling of the uterus
Like endometriosis, adenomyosis can take several years to diagnose after symptom onset [2]. In order to diagnose adenomyosis, your provider will need to rule out uterine fibroids, endometriosis, and endometrial polyps, the symptoms of which all mimic adenomyosis symptoms. A healthcare provider who suspects adenomyosis based on patient symptoms may perform a pelvic exam and order an ultrasound and/or an MRI (magnetic resonance imaging). MRI provides the clearest picture. The only definitive diagnosis, though, for adenomyosis is through actual visualization and examination of the uterus after removal (hysterectomy).
Who is at risk for adenomyosis?
The Cleveland Clinic estimates that 20-65% of women may have adenomyosis, although some cases are asymptomatic. Women may be more likely to develop adenomyosis if they:
- Have been pregnant multiple times
- Are between 35 and 50 years old
- Have had surgery on their uterus, including a Cesarean section (C-section), fibroid removal, or dilation & curettage (D&C)
Adenomyosis is most often suspected in women in their 40s or 50s who have not yet gone through menopause, but it may very well be common in young women as well, who may present with unexplained infertility. The incidence of adenomyosis is disproportionately high among black women [3]
The impact of adenomyosis on fertility and pregnancy
While many women with adenomyosis are able to get pregnant, for some women, adenomyosis and infertility do appear to be linked [4]. Women who experience both adenomyosis and endometriosis appear most likely to have difficulty becoming and staying pregnant.
During pregnancy, according to the Cleveland Clinic, adenomyosis may specifically increase risk of both miscarriage and preterm labor. Research studies suggest a connection between adenomyosis and increased risk of second-trimester miscarriage, pre-eclampsia, placental disorders, preterm premature rupture of membranes (PPROM), having a small for gestational age (SGA) baby, and/or needing a C-section [5].
Treatments for adenomyosis are few and far-between
Unfortunately, as this research summary of what’s known about adenomyosis notes “so far, few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed, and no drugs labeled for adenomyosis are currently available” [6].
In good news, though, adenomyosis typically resolves after menopause as estrogen levels drop. Consequently “watchful waiting” and various symptom relief measures are often recommended for women who don’t experience debilitating symptoms. Of course, this is unhelpful for women of childbearing age who wish to become pregnant, and are experiencing infertility due to their condition.
Over-the-counter treatment
Over-the-counter pain medications like Ibuprofen are often recommended for adenomyosis-related pain.
Prescription treatments
GnRH agonists are widely used as an effective and non-invasive treatment for uterine adenomyosis, once the diagnosis is confirmed. While not they do not cure adenomyosis, GnRH agonists may cause remission and temporary relief of symptoms. (GnRH agonists may also be used to treat endometriosis with good remissions, but not cures.)
Hormonal birth control
Hormonal birth control is sometimes prescribed to reduce pain or bleeding by stopping the normal fluctuations of estrogen and progesterone that occur during a natural menstrual cycle. But UptoDate, an evidence-based resource for medical professionals cautions that:
“While estrogen-progestin contraceptives are frequently used as primary treatment for dysmenorrhea [painful periods], there are little data on the efficacy of these contraceptives specifically for adenomyosis.”
In addition to combined oral contraceptives, sometimes progestin-only contraception is prescribed, like the progestin mini-pill or an IUD, but each of these comes with its own set of serious risks and side effects, some of which may be deadly.
Sadly, the lack of therapeutic benefit does not stop many physicians from prescribing hormonal contraception for painful periods that may be due to adenomyosis. In fact, these “treatments,” while they may mask symptoms, can hide the progression of the disease, making it difficult for women to get timely, effective treatments that may slow progression or cause disease remission.
Naturopathic options
Naturopathic doctor Lara Briden has a slightly different take from the mainstream medical approach on appropriate treatment for endometriosis (which, as mentioned above, is similar to adenomyosis). Specifically, Dr. Briden believes that “endometriosis is not a hormonal condition.” She acknowledges that “it’s affected by estrogen” (which is clearly evidenced by the fact that menopause brings an end to symptoms, as estrogen levels drop) but insists that it “is not caused by estrogen or ‘estrogen dominance.’” Instead, she believes “endometriosis is a whole-body inflammatory and immune disease, and possibly a microbial disease.”
Consequently, Dr. Briden’s treatment recommendations for patients with endometriosis or adenomyosis involve eating an anti-inflammatory diet, specifically one that avoids cow’s dairy (A1 casein), and adding certain supplements like curcumin and zinc. She also recommends trying oral or vaginal bioidentical progesterone to improve immune function, as some literature suggests that progesterone can inhibit inflammatory responses, which may provide some relief from symptoms related to inflammation (although there is no evidence as of yet that oral or vaginal progesterone can improve adenomyosis as a disease).
However, taking bioidentical progesterone every day without regard to where you are in your menstrual cycle could cause hormonal imbalances! Healthcare professionals trained in restorative reproductive medicine are educated on prescribing bioidentical progesterone timed with the appropriate phase of the woman’s cycle to achieve the best outcomes. Likewise, learning a fertility awareness method (FAM) is essential for a woman to accurately identify the particular phases of her menstrual cycle.
Surgery
Women who don’t achieve effective symptom relief with the measures described above have several surgical options with varying degrees of invasiveness and efficacy. Minimally invasive techniques include 1) endometrial ablation, which burns away part of the lining of the uterus (but does not penetrate the muscle layer where the adenomyosis actually resides), 2) uterine artery embolization, which decreases blood supply to the part of the uterus where the adenomyosis is believed to be located, and 3) myometrial reduction, which removes the problematic section of the uterus (however, it is extremely difficult to visually identify such areas with accuracy, and some areas of adenomyosis may be deep within the wall of the uterus). As various sources note, the use of minimally invasive techniques for adenomyosis is controversial, and much is unknown about potential long-term risks of each [7].
The only definitive “cure” for adenomyosis is a hysterectomy or surgical removal of the uterus. The ovaries need not be removed since adenomyomas do not grow there. Hysterectomy is considered a last resort because it renders a woman infertile.
As is often the refrain in women’s health, more research is clearly needed on adenomyosis. Despite affecting a significant proportion of women with pain, heavy bleeding, and infertility, very little attention has been paid to what can be a debilitating condition. Like endometriosis, polycystic ovary syndrome (PCOS), uterine fibroids, and other diseases of the female reproductive system, bandaid solutions (like hormonal birth control) or drastic measures (like hysterectomies) are poor substitutes for treatments that solve root causes of illness, while preserving a woman’s fertility.
References:
[1] Di Donato N, Montanari G, Benfenati A, Leonardi D, Bertoldo V, Monti G, Raimondo D, Seracchioli R. Prevalence of adenomyosis in women undergoing surgery for endometriosis. Eur J Obstet Gynecol Reprod Biol. 2014 Oct; 181():289-93. [2] Morassutto C, Monasta L, Ricci G, Barbone F, Ronfani L. Incidence and Estimated Prevalence of Endometriosis and Adenomyosis in Northeast Italy: A Data Linkage Study. PLOS ONE 11(4): e0154227. https://doi.org/10.1371/journal.pone.0154227 [3] Yu O, Schulze-Rath R, Grafton J, Hansen K, Scholes D, Reed SD. Adenomyosis incidence, prevalence and treatment: United States population-based study 2006-2015. Am J Obstet Gynecol. 2020 Jul;223(1):94.e1-94.e10. doi: 10.1016/j.ajog.2020.01.016. Epub 2020 Jan 15. PMID: 31954156. [4], [5], and [6] Vannuccini S, Petraglia F. Recent advances in understanding and managing adenomyosis. F1000Res. 2019;8:F1000 Faculty Rev-283. Published 2019 Mar 13. doi:10.12688/f1000research.17242.1 [7] Oliveira MAP, Crispi CP Jr, Brollo LC, Crispi CP, De Wilde RL. Surgery in adenomyosis. Arch Gynecol Obstet. 2018 Mar;297(3):581-589. doi: 10.1007/s00404-017-4603-6. Epub 2017 Dec 2. PMID: 29197987.Additional Reading:
If you’re considering a hysterectomy for endometriosis, read this first
Uterine Fibroids: Causes, Symptoms, and Treatments
The Difficulties of Diagnosing and Categorizing the Stages of Endometriosis
