What is the Best Treatment for Adenomyosis?

Best Treatment for Adenomyosis: Relief Options for Pain & Fertility

Adenomyosis is a complex and often debilitating gynaecological condition that can severely diminish a woman's quality of life. It's defined by the presence of endometrial tissue (the kind that normally lines the uterus) growing aberrantly within the muscular wall of the uterus itself.

The abnormal growth of tissue can lead to a variety of discomforting symptoms such as chronic pelvic pain, heavy or extended menstrual bleeding, and, in certain instances, infertility or other reproductive disorders.

A thorough understanding of the underlying pathophysiology, accurate diagnosis, and tailored treatment strategies is essential for optimal disease management. In this article, we’ll examine the leading treatment approaches, potential causes, stages, and long-term outlook for individuals living with adenomyosis.

What is the Cause of Adenomyosis?

The exact cause of adenomyosis remains unclear, but some well-supported researchers try to elucidate its plausible development:

• Endometrial Gland Invasion : The most widely accepted hypothesis predicts the invasion of the myometrial wall by endometrial glands due to chronic uterine inflammation, tissue injury, or surgical interventions like caesarean sections or dilation and curettage (D&C).
• Developmental Theory : This theory proposes that the endometrial tissue could become misplaced in the myometrium during foetal life and lie dormant until prompted by hormonal fluctuations in later life.
• Stem Cell Theory : The bone marrow stem cells are also postulated to migrate to the uterus and form endometrial-type cells in the muscular layer of the uterus, thus causing adenomyosis.

Risk factors involved are:

• Age between 35 and 50 years
• Multiparity
• History of uterine surgery
• High oestrogen levels

These etiologic mechanisms trigger inflammatory responses and endometrial wall thickening and result in the typical symptoms of adenomyosis.

What Are the Symptoms of Adenomyosis?

While some women remain asymptomatic, most of them develop a range of uncomfortable symptoms, including:

• Severe dysmenorrhea (period pain), usually more painful and long-lasting than usual period pain
• Menorrhagia (heavy periods), potentially causing anaemia and tiredness in the long run
• Chronic pelvic pain is present throughout the menstrual cycle and not only during menstruation.
• Painful intercourse, specifically deep pelvic discomfort experienced during or after sexual activity.
• Uterine distension: the uterus could be tender or enlarged on palpation.
• Fertility or inability to conceive, especially in comorbid cases

Since adenomyosis cross-symptomatically overlaps with other gynaecological conditions such as endometriosis or fibroids, this condition is generally underdiagnosed or misdiagnosed, and delayed treatment ensues.

How is Adenomyosis Diagnosed?

Accurate diagnosis is essential to guide proper treatment interventions:

• Transvaginal Ultrasound (TVUS) : This is most often the initial imaging technique. It may exhibit typical findings, such as myometrial cysts, junctional zone thickening, or asymmetrical uterine wall thickening, all of which are indicative of adenomyosis.
• Magnetic Resonance Imaging (MRI) : MRI is superior to ultrasound in sensitivity and specificity. It is particularly valuable in outlining the extent, depth, and nature of the infiltration of the lesion, which helps in planning for the treatment.
• Histopathological Examination : Diagnosis is generally established by histopathological examination of resected uterine tissue in a hysterectomy, illustrating the presence of endometrial glands within the myometrium.

In contrast to uterine fibroids, which are seen as discrete, well-defined masses, adenomyosis is seen as an ill-defined or diffuse lesion and thus is harder to diagnose with imaging alone.

What is Stage 1 Adenomyosis?

Adenomyosis lacks a universally employed staging system similar to cancer. There are some clinical findings and imaging techniques that try to grade it by the depth of lesions and extent. Adenomyosis Stage 1 generally depicts superficial or focal invasion of the inner myometrium, specifically in the area of the endometrial–myometrial junction.

Below is a breakdown:

• Symptom Presentation : Patients can develop few to moderate symptoms, including mild pelvic cramps, slightly heavier periods, or more fatigue during menstruation.
• Challenges in Diagnosis : Frequently misdiagnosed or mistaken for incipient endometriosis, myometrial cysts, or tiny fibroids, especially where imaging is faint or unclear.
• Health Impacts : Already in an early phase, adenomyosis can cause heavy menstrual discomfort, which may interfere with daily functions and mental status.
• Clinical Significance : Early detection of adenomyosis makes it possible to treat it on time, which contributes to controlling the symptoms and maintaining fertility, particularly in patients of reproductive age.

What is the Best Treatment for Adenomyosis?

Treatment is highly individualised and depends on a variety of factors, including severity of symptoms, age, desire for future fertility, and disease severity. No cure (except hysterectomy) is available, but the following medical and surgical treatments have been effective:

Pharmacological Treatment

Hormonal Therapy

Hormone therapies suppress oestrogen's activity, thereby hindering the progression of adenomyosis. These include:

• Gonadotropin-Releasing Hormone (GnRH) Agonists: Leuprolide causes a reversible menopause condition to reduce adenomyotic tissue.
• Progestins: Dienogest and medroxyprogesterone suppress bleeding and undo oestrogenic stimulation.
• Levonorgestrel-Releasing IUD (LNG-IUS): Local progestin release, causing regulation of menorrhagia and uterine shrinkage.
• Combined Oral Contraceptives: Alleviate symptoms but are not as effective as progestins or IUDs.

Non-steroidal anti-inflammatory drugs (NSAIDs)

• Recurrent dysmenorrhea and menstrual cramps, especially premenstrual, are not curable.
• Hormonal treatment is symptomatic and not curative. Symptoms also have a tendency to recur upon withdrawal.

Non-hormonal and Minimally Invasive Therapies

Uterine Artery Embolisation (UAE)

• This technique deprives the adenomyotic tissue of its blood supply, which atrophies. UAE is uterine-sparing and beneficial in controlling pain and bleeding but can impact future fertility.

High-Intensity Focused Ultrasound (HIFU)

• An image-guided, non-invasive technique that concentrates ultrasound waves upon target tissue and ablates it. HIFU shows promise for fertility preservation in women, but as a newer treatment, it's not yet well-established.

Surgical Management

• Conservative Surgery (Adenomyomectomy) : It simply removes the adenomyotic tissue, preserving the uterus. It is most suitable for women who might plan future pregnancies but is technically challenging, particularly when there is diffuse disease.
• Definitive Surgery (Hysterectomy) : This method serves as the final cure for extensive or resistant adenomyosis. It involves complete removal of the uterus, with or without ovaries, depending on the patient's age and the presence or absence of other gynaecologic disorders.

Hysterectomy is followed by long-term relief from pain and heavy menstrual bleeding and is the only absolute treatment for adenomyosis.

Can Adenomyosis Be Cured?

There is no definite cure except a hysterectomy. Other therapies yield symptom relief and improvement in quality of life. Recurrence generally occurs upon stopping medical treatments. Patient education and follow-up are therefore necessary in controlling expectations.

Does Adenomyosis Affect Fertility?

Yes, adenomyosis could affect fertility in several ways:

• Abnormal uterine contractility, which impairs sperm motility and the implantation of the embryo
• Inflammatory processes, possibly giving rise to an unfavourable uterine environment that inhibits implantation
• Concomitant endometriosis adds to reduced reproductive efficiency and facilitates conception.

Infertile women may seek a consultation with a specialist fertility expert to have a proper examination done. In the most favourable conditions, ART, like IVF, could be prescribed, following some duration of hormonal therapy to suppress the symptoms and prepare the uterine environment for implantation.

Lifestyle Modifications and Supportive Care

Although lifestyle changes won't cure adenomyosis, they are an adjunctive measure in alleviating the severity of symptoms and overall quality of life. They are particularly helpful when combined with medical therapy:

• Daily Exercise: Daily exercise coupled with low-impact physical activity such as walking, swimming, or yoga enhances circulation, alleviates pelvic congestion, and comforts menstrual pain.
• Anti-inflammatory Diet: Dietary intake of omega-3 fatty acids, green leafy vegetables, whole grains, and antioxidants might help reduce systemic inflammation and hormonal alterations that heighten symptoms.
• Stress Management :Stress could also potentially heighten pelvic pain and hormonal imbalance. Yoga, deep breathing, guided meditation, and journaling could improve emotional stability and resilience to pain.
• Complementary Therapies :Massage, pelvic floor physiotherapy, and acupuncture are some of the procedures that provide further pain relief and improve pelvic function when added to standard therapy.

These lifestyle changes, while not a complete solution per se, do enhance quality of life and decrease dependency on drug therapy.

Conclusion

Adenomyosis needs a tailored, multidisciplinary treatment plan for proper relief of symptoms. Although measures for non-surgical management can benefit women in the initial stage or upcoming fertility-seeking patients, eventual treatments such as hysterectomy are best suited for long-term management.