Dr Raul Chercehes, consultant gynecologist from Bucharest, Romania.
What is adenomyosis and what are its symptoms?
Adenomyosis is a condition in which tissue similar to the endometrium, the lining that lines the inside of the uterus, grows in the thick muscle of the uterus, called the myometrium.
The exact causes of adenomyosis are not fully understood, but there are several theories and factors that may contribute to the development of this condition:
Invasion theory: According to this theory, endometrial tissue migrates into the uterine muscle through tears in the uterine wall, such as scars from previous surgeries (such as cesarean section) or injuries due to inflammation.
Metaplasia theory: This theory suggests that uterine muscle (myometrium) cells transform into endometrial-like cells under the influence of hormonal or other factors.
Hormonal factors: Hormones, especially estrogen, appear to play an important role in the development of adenomyosis. High levels of estrogen in the uterus of certain women favor the growth and proliferation of endometrial tissue.
Inflammatory factors: Chronic inflammation of the uterus or other pelvic organs can contribute to adenomyosis. This can be caused by repeated infections or other pelvic inflammatory conditions.
Genetic factors: There is some evidence to suggest that genetic predisposition may play a role in the development of adenomyosis, but this aspect is still being researched and understood.
Factors related to age and parity: Adenomyosis is more common in middle-aged women and those who have had several children. This could be related to hormonal changes and the impact of pregnancy on the uterus over time.
It is important to note that these causes can interact with each other and vary from person to person. Adenomyosis is a complex condition and research continues to better understand its developmental mechanisms.
Symptoms of adenomyosis can include chronic and intense pelvic pain, severe menstrual cramps, heavy and prolonged menstrual bleeding, pain during intercourse, bloating, and sometimes infertility through deformation of the uterine cavity and decreased implantation rate or abortion.
What are the types of adenomyosis and how can it be diagnosed?
There are two main types of adenomyosis: focal and diffuse. Focal adenomyosis refers to the localized presence of endometrial tissue within the uterine muscle, while diffuse adenomyosis involves a wider spread of this tissue.
The diagnosis can be established by a combination of a detailed history, clinical examination and imaging examinations. These patients must be listened to and believed. We perform a complete clinical history, gynecological examination, but the diagnosis is made by transvaginal ultrasound. Complementary – adenomyosis can also be seen at hysteroscopy or nuclear magnetic resonance.
Unlike endometriosis, in adenomyosis the only surgical option to cure the disease is hysterectomy. When can hysterectomy be performed, especially in young patients?
The choice of the type of treatment for adenomyosis must be personalized and individualized and depends on a number of factors:
Severity of symptoms: If the symptoms of adenomyosis are moderate to severe and affect the patient’s quality of life, more radical treatment may be necessary
Desire for fertility: For women who wish to become pregnant in the future, treatments that preserve the uterus and fertility may be preferred. In this case, hormone therapies or surgery that preserves the uterus will be considered.
Medical history: The patient’s medical history, including previous surgeries or other medical conditions, may influence treatment options and associated risks.
Reaction to previous treatments: If the patient has previously tried certain treatments and they were not effective or were associated with unwanted side effects, this may influence the decision to try other therapeutic options.
Patient preferences: It is important to consider the patient’s preferences and values in the decision-making process. Some women may prefer conservative treatment that preserves the uterus, while others may be more willing to opt for hysterectomy to relieve symptoms. Also, many women are against hormonal treatments, either because they are real contraindications or because they are misinformed or out of fear. We always respect the patient’s opinion.
Age of the patient: The age of the patient can influence the treatment decision. For older women who no longer wish to become pregnant, options including hysterectomy may be considered earlier.
Hysterectomy is considered by many to be the only curative option for adenomyosis, because it completely removes the uterus – the organ where the problem is. However, in young patients who wish to preserve fertility, hysterectomy may be reserved for severe cases or those where other treatment options have failed to provide relief.
In general, in young patients, hysterectomy is the last option, when all others have been exhausted. We take into account the severity of the symptoms and the completion of family planning. If all these factors are aligned – we reach the decision of hysterectomy, of course with the preservation of the ovaries – in order not to induce an early menopause.
Hormonal treatment is a recommended therapeutic option for many women who suffer from adenomyosis. What are these treatments and what are their benefits and risks?
Hormonal treatment – is used in the management of adenomyosis symptoms. It has no curative role. This includes oral contraceptives, either combined or progestogen-only, hormone-releasing intrauterine devices (such as Mirena), hormone injections, hormone patches or implants.
They work by changing the hormonal balance of the body and by controlling the menstrual cycle, namely:
Ovulation suppression: Hormonal contraceptives suppress the release of eggs from the ovaries, thereby reducing the production of estrogen during the menstrual cycle. Because high estrogen levels are associated with the development and growth of endometrial tissue, suppressing ovulation may help reduce the abnormal growth of endometrial tissue in the uterine muscle in adenomyosis.
Thinning of the endometrium: All hormonal preparations can cause thinning of the endometrium. This can reduce heavy menstrual bleeding and pain associated with adenomyosis.
Preventing the formation and growth of endometrial lesions: By suppressing the menstrual cycle and thinning the endometrium, hormone therapy can reduce the formation and growth of new adenomyosis lesions in the uterine muscle.
Control of symptoms: Finally, as I said – Hormonal treatment has a fine goal – control of symptoms associated with adenomyosis, such as chronic pelvic pain and severe menstrual cramps, pain on contact, prolonged or even intermenstrual bleeding. However, they have no effect on infertility.
And although we have listed multiple benefits, there may also be risks associated with the use of these therapies, such as: changes in body weight, changes in mood, libido, increased risk of blood clots. Perhaps the biggest risk of hormone therapy is – futility. It does not work for all patients.
Adenomyosis is a disease of the uterus. One of the therapeutic methods is Mirena. What is this device and how does it work?
The Mirena IUD is an intrauterine device that we insert into the uterus and that releases a hormone called levonorgestrel, a derivative of progesterone.
It works by thinning the uterine lining and reducing menstrual bleeding and pain associated with adenomyosis. In addition, the expression of aromatase and COX2 decreases – 2 absolutely important enzymes in the formation of local estrogen – the main hormone in adenomyosis.
When can the placement procedure be carried out? Is a certain preparation necessary? Is it only done on certain days of the cycle?
The IUD placement procedure can be performed routinely during a gynecological office visit. Although it can be fitted at any time during the menstrual cycle – we prefer the placement to be performed during menstruation, when the cervix is more open – the fitting being easier both for us as gynecologists and for the patients. I repeat it is not mandatory. No special preparation is needed before the procedure, but the doctor may recommend taking a pain reliever before the placement.
Is it painful to insert and how do you know when it’s still in place?
Insertion of the IUD may be slightly uncomfortable and associated with mild cramping, but is usually not painful and does not require general anesthesia, although local anesthesia should be performed. There is a little discomfort during installation – but that’s about it. The doctor will use an instrument called a speculum to see the cervix and then insert the IUD through the cervical canal into the uterine cavity. However, insertion can be difficult in patients with severe adenomyosis – the uterine cavity being very deformed. After placement, the doctor will check the position of the IUD with transvaginal ultrasound, maybe even with 3D reconstruction.
What are the complications that can occur?
Complications associated with having a Mirena inserted can include:
rejection – being a foreign body – in some patients the uterus cannot bear it – this is manifested by menometrorrhagia (small bleeding) corns and uterine cramps. The first 3 months are decisive.
uterine perforation during insertion
the involuntary expulsion of the device – the risk being higher in the first 6 months after installation, but also in people with many births and large uteruses
pelvic infections;
increased risk of ectopic pregnancy – progesterone affecting tubal motility – slowing the movement of cilia in the tubes and increasing the risk of ectopic pregnancy;
weight gain – mainly due to water retention
How effective is it and for how long?
The efficiency of the Mirena IUD in the treatment of adenomyosis is considered good – if we talk about the painful symptoms. Studies have shown a significant reduction in dysmenorrhea and dyspareunia. In terms of bleeding, the efficiency is very good – many of the patients even reach the absence of menstrual bleeding – altogether. However, there are also many patients – for whom MIRENA does not work, the adenomyosis progresses and the symptoms get worse with the IUD. The cause is being studied. It may have to do with the different etiology of some forms of adenomyosis – let’s not forget that Mirena is a symptomatic treatment – it does not affect the cause. The studies missed that although it has an effect on the symptoms – the Mirena IUD has no effect on the changes inside the uterus.
Until recently – its duration of action was considered to be 5 years – more recent studies have shown that even after 10 years the IUD releases a smaller amount of hormone. Mirena can be removed at any time.