Managing adenomyosis

Adenomyosis is a benign condition characterised by the ectopic growth of endometrial tissue within the myometrium of the uterus. It is most common in women in their 30’s and 40’s and is estimated to affect up to 15% of women.

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Clinical presentation of adenomyosis

The clinical presentation of adenomyosis typically includes abnormal uterine bleeding (AUB) (e.g. dysmenorrhoea, menorrhagia, or irregular bleeding). The presentation may also include dyspareunia and chronic pelvic pain, which are common to many other conditions, including uterine fibroids, endometriosis, and endometrial hyperplasia. Adenomyosis coexists with endometriosis in up to 80% of cases. Subfertility may also be a presenting condition.

History

It is important to take a comprehensive history, including menstrual history, the relation of symptoms to the menstrual cycle, symptom onset and severity, and assess for any red flag features that may indicate malignancy, such as weight loss.

Clinical examination

Clinical examination, including pelvic examination, is indicated in all women with suspected adenomyosis to assess the uterine size, shape and presence of any masses or tenderness. Often with adenomyosis, the uterus is diffusely and symmetrically enlarged and tender. Where menorrhagia is a presenting symptom, it is important to assess cardiovascular status, including pulse and blood pressure.

A full blood count may be indicated to evaluate for anaemia. Other laboratory investigations may be indicated to exclude differential diagnoses such as polycystic ovarian syndrome (PCOS), hypothyroidism or coagulation disorders.

Investigation

The first-line investigation in suspected adenomyosis is pelvic ultrasonography. Transabdominal and transvaginal ultrasound provides an overview of uterine anatomy and may identify pathologies such as fibroids, tumours (such as leiomyomas), endometrial thickening or adenomyosis. Magnetic resonance imaging (MRI) may then be indicated to delineate the uterine architecture further. All women over the age of 45 with AUB should have an endometrial biopsy. A competent primary care practitioner may perform this; however, it is recommended to be performed via hysteroscopy for women with heavy menstrual bleeding. A definitive diagnosis can only be made histologically following an endometrial biopsy or hysterectomy.

Management of adenomyosis

Management of adenomyosis is dependent upon symptom severity and the woman’s reproductive goals. A definitive diagnosis is not required to initiate treatment.

The first-line management includes pain management using simple analgesia such as nonsteroidal anti-inflammatory drugs (NSAIDs), which can be commenced whilst investigations are ongoing. Hormonal therapies such as combined hormonal contraception (CHC) or a levonorgestrel-releasing intrauterine device (LNG-IUD) are further management options in women with adenomyosis who do not desire fertility.

In cases where medical management is ineffective and a woman does not want future fertility, surgical management with a hysterectomy may be indicated. There are also evolving, less invasive surgical techniques such as endometrial artery embolisation or ligation and endometrial excision or ablation.

Chronic pelvic pain, including adenomyosis, is often underdiagnosed in women and can have a significant effect of quality of life. Therefore it is important to investigate appropriately and have a patient-centred and holistic approach to the management of this condition in primary care.

Dr Samantha Miller, MBChB

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References

1.    Royal College of Obstetricians and Gynaecologists (2012). The Initial Management of Chronic Pelvic Pain. https://www.rcog.org.uk/media/muab2gj2/gtg_41.pdf 
2.    NHS Inform (2023). Adenomyosis. https://www.nhsinform.scot/healthy-living/womens-health/girls-and-young-women-puberty-to-around-25/periods-and-menstrual-health/adenomyosis/ 
3.    NHS (2023). Adenomyosis. https://www.nhs.uk/conditions/adenomyosis/ 
4.    Taran, F. A., Stewart, E. A., & Brucker, S. (2013). Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy. Geburtshilfe und Frauenheilkunde, 73(9), 924–931. https://doi.org/10.1055/s-0033-1350840 
5.    BMJ Best Practice (2023). Assessment of abnormal uterine bleeding. https://bestpractice.bmj.com/topics/en-gb/171 
6.    Health Direct (2022). Adenomyosis. https://www.healthdirect.gov.au/adenomyosis 
7.    GP Notebook (2021). Adenomyosis. https://gpnotebook.com/en-GB/pages/gynaecology/adenomyosis