Adenomyosis
Encyclopedia
Adenomyosis is a medical condition characterized by the presence of ectopic glandular tissue found in muscle
. The term adenomyosis is derived from the terms adeno- (meaning gland
), myo- (meaning muscle
), and -osis (meaning condition). Previously named as endometriosis interna, adenomyosis actually differs from endometriosis and these two disease entities are found together in only 10% of the cases.
It usually refers to ectopic endometrial tissue
(the inner lining of the uterus
) within the myometrium
(the thick, muscular layer of the uterus). The term "adenomyometritis" specifically implies involvement of the uterus.
The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea
& menorrhagia
, respectively). However, because the endometrial glands can be trapped in the myometrium
, it is possible to have increased pain without increased blood. (This can be used to distinguish adenomyosis from endometrial hyperplasia
; in the latter condition, increased bleeding is more common.)
In adenomyosis, basal endometrium penetrates into hyperplastic myometrial fibers. Therefore, unlike functional layer, basal layer does not undergo typical cyclic changes with menstrual cycle.
Adenomyosis may involve the uterus focally, creating an adenomyoma
. With diffuse involvement, the uterus becomes bulky and heavier.
, tubal ligation
, pregnancy termination, and any pregnancy
. It can be linked with endometriosis
.
Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen (Estrogen Dominance). Near the age of 35, women typically cease to create as much natural progesterone
, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen
.
Adenomyosis correlates with abnormal amounts of multiple substances, possibly indicating a causative link in its pathogenesis, although correlation does not imply causation
:
may be imaged using ultrasound
(US) or magnetic resonance imaging
(MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality may show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids
.
MRI provides better diagnostic capability due to the increased soft tissue differentiation, allowable through higher spatial and contrast resolution. MRI is limited by other factors, but not by calcified uterine fibroids (as is ultrasound). In particular, MRI is better able to differentiate adenomyosis from multiple small uterine fibroids
. The uterus will have a thickened junctional zone
with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone
greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.
MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
Exact diagnosis of adenomyosis only possible in posthysterectomy specimen.
because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain.
Those that believe an excess of estrogen (Estrogen Dominance)is the cause of Adenomyosis, or that it aggravates the symptoms, recommend avoiding products with xenoestrogen
s and/or recommend taking Natural Progesterone Cream which may help balance the hormone levels.
Chinese herbal supplements DIM and Myomin are claimed to reduce excess estrogen, shrink fibroids and reduce significantly the adenomyosis symptoms. DIM is a blend of cruciferous vegetable extracts including broccoli, cauliflower, cabbage and brussel sprouts. Research shows it helps metabolize unhealthy circulating estrogens (estrone, estradiol) into the good form (estriol).
Myomin is an all natural formula of Chinese herbs that has been shown to help metabolize unhealthy estrogens and promote proper hormonal balance. Studies show that it also inhibits aromatase, an enzyme that converts androgens (testosterone) into estrogen.In addition to that, it competes with estradiol at the estrogen receptors of target cells. This is why Myomin is so effective for estrogen-dominant conditions such as cysts and fibroids (International Journal of Integrative Oncology. Mar 2008; 2(1):7-15).
The operation 'Hysterectomy' should only be considered as a very last form of treatment option for this condition once full understanding of the long term effects have been read and understood. See Hysterectomy Education Resources and Services (HERS) website which explains the longer term after effects to having the uterus, cervix and/or ovaries removed.
ta and/or endometriosis
.
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
. The term adenomyosis is derived from the terms adeno- (meaning gland
Gland
A gland is an organ in an animal's body that synthesizes a substance for release of substances such as hormones or breast milk, often into the bloodstream or into cavities inside the body or its outer surface .- Types :...
), myo- (meaning muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...
), and -osis (meaning condition). Previously named as endometriosis interna, adenomyosis actually differs from endometriosis and these two disease entities are found together in only 10% of the cases.
It usually refers to ectopic endometrial tissue
Endometrium
-Function:The endometrium is the innermost glandular layer and functions as a lining for the uterus, preventing adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the uterine cavity. During the menstrual cycle or estrous cycle, the endometrium grows to a...
(the inner lining of the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
) within the myometrium
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
(the thick, muscular layer of the uterus). The term "adenomyometritis" specifically implies involvement of the uterus.
The condition is typically found in women between the ages of 35 and 50. Patients with adenomyosis can have painful and/or profuse menses (dysmenorrhea
Dysmenorrhea
Dysmenorrhea is a gynecological medical condition of pain during menstruation that interferes with daily activities, as defined by ACOG and others. Still, dysmenorrhea is often defined simply as menstrual pain, or at least menstrual pain that is excessive...
& menorrhagia
Menorrhagia
Menorrhagia is an abnormally heavy and prolonged menstrual period at regular intervals. Causes may be due to abnormal blood clotting, disruption of normal hormonal regulation of periods or disorders of the endometrial lining of the uterus...
, respectively). However, because the endometrial glands can be trapped in the myometrium
Myometrium
The myometrium is the middle layer of the uterine wall, consisting mainly of uterine smooth muscle cells , but also of supporting stromal and vascular tissue...
, it is possible to have increased pain without increased blood. (This can be used to distinguish adenomyosis from endometrial hyperplasia
Endometrial hyperplasia
Endometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus.Most cases of endometrial hyperplasia result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily...
; in the latter condition, increased bleeding is more common.)
In adenomyosis, basal endometrium penetrates into hyperplastic myometrial fibers. Therefore, unlike functional layer, basal layer does not undergo typical cyclic changes with menstrual cycle.
Adenomyosis may involve the uterus focally, creating an adenomyoma
Adenomyoma
Adenomyoma is a tumor including components derived from glands and muscle . It is a type of complex and mixed tumor.In Ob/Gyn contexts, it is a form of adenomyosis that forms a mass or growth around the tissue of the inner uterus....
. With diffuse involvement, the uterus becomes bulky and heavier.
Causes
The cause of adenomyosis is unknown, although it has been associated with any sort of uterine trauma that may break the barrier between the endometrium and myometrium, such as a caesarean sectionCaesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
, tubal ligation
Tubal ligation
Tubal ligation or tubectomy is a surgical procedure for sterilization in which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents eggs from reaching the uterus for fertilization...
, pregnancy termination, and any pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
. It can be linked with endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
.
Some say that the reason adenomyosis is common in women between the ages of 35 and 50 is because it is between these ages that women have an excess of estrogen (Estrogen Dominance). Near the age of 35, women typically cease to create as much natural progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
, which counters the effects of estrogen. After the age of 50, due to menopause, women do not create as much estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
.
Adenomyosis correlates with abnormal amounts of multiple substances, possibly indicating a causative link in its pathogenesis, although correlation does not imply causation
Correlation does not imply causation
"Correlation does not imply causation" is a phrase used in science and statistics to emphasize that correlation between two variables does not automatically imply that one causes the other "Correlation does not imply causation" (related to "ignoring a common cause" and questionable cause) is a...
:
- Endometrial IL-18 receptor mRNA and the ratio of IL-18 binding protein to IL-18Interleukin 18Interleukin-18 also known as IL18 is a protein which in humans is encoded by the IL18 gene. The protein encoded by this gene is a proinflammatory cytokine.- Function :...
are significantly increased in adenomyosis patients in comparison to normal people. - Leukemia inhibitory factorLeukemia inhibitory factorLeukemia inhibitory factor, or LIF, an interleukin 6 class cytokine, is a protein in cells that affects cell growth and development.-Function:LIF derives its name from its ability to induce the terminal differentiation of myeloid leukemic cells...
is dysregulated in the endometrium and uterine flushing fluid of women with adenomyosis during the implantation window.
Diagnosis
The uterusUterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
may be imaged using ultrasound
Ultrasound
Ultrasound is cyclic sound pressure with a frequency greater than the upper limit of human hearing. Ultrasound is thus not separated from "normal" sound based on differences in physical properties, only the fact that humans cannot hear it. Although this limit varies from person to person, it is...
(US) or magnetic resonance imaging
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
(MRI). Transvaginal ultrasound is the most cost effective and most available. Either modality may show an enlarged uterus. On ultrasound, the uterus will have a heterogeneous texture, without the focal well-defined masses that characterize uterine fibroids
Leiomyoma
A leiomyoma is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.- Etymology:* Greek:** λεῖος leios "smooth"...
.
MRI provides better diagnostic capability due to the increased soft tissue differentiation, allowable through higher spatial and contrast resolution. MRI is limited by other factors, but not by calcified uterine fibroids (as is ultrasound). In particular, MRI is better able to differentiate adenomyosis from multiple small uterine fibroids
Leiomyoma
A leiomyoma is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.- Etymology:* Greek:** λεῖος leios "smooth"...
. The uterus will have a thickened junctional zone
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
with diminished signal on both T1 and T2 weighted sequences due to susceptibility effects of iron deposition due to chronic microhemorrhage. A thickness of the junctional zone
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
greater than 10 to 12 mm (depending on who you read) is diagnostic of adenomyosis (<8 mm is normal). Interspersed within the thickened, hypointense signal of the junctional zone, one will often see foci of hyperintensity (brightness) on the T2 weighted scans representing small cystically dilatated glands or more acute sites of microhemorrhage.
MRI can be used to classify adenomyosis based on the depth of penetration of the ectopic endometrium into the myometrium.
Exact diagnosis of adenomyosis only possible in posthysterectomy specimen.
Typical Symptoms
Some women with Adenomyosis do not experience any symptoms, while others may have severe, debilitating symptoms. The Endometrial implants that grow into the wall of the uterus bleed during menstruation, (the same as endometrial tissue bleeds) is discharged vaginally as menstrual bleeding. The vaginal pressure can be severe enough to feel like the uterus is trying to push out through the vagina, like the last stage of labor when the baby's head pushes into the cervix. Other symptoms include;- Intense debilitating pain all the time and/or
- Acute & increasing pain at menstration and ovulation
- Strong 'contraction' feel of uterus
- Abdominal cramps
- A 'bearing' down feeling
- Pressure on bladder
- Dragging sensation down thighs and legs
- Heavy bleeding and flooding
- Large blood clots
- Prolonged bleeding ie; up to 8-14 days
Treatment
Treatment options range from use of Natural Progesterone Cream, NSAIDs, hormonal suppression, anti inflammatory pain killers and IUD Coil for short term symptomatic relief (although IUD may cause further irritation of the uterus). Women with adenomyosis fail endometrial ablationEndometrial ablation
Endometrial ablation is a medical procedure that is used to remove or destroy the endometrial lining of a uterus. This technique is most often employed for people who suffer from excessive or prolonged bleeding during their menstrual cycle but cannot or do not wish to undergo a hysterectomy. ...
because the ablation only affects the surface endometrial tissue, not the tissue that has grown into the muscle lining. This remaining tissue is still viable and will continue to cause pain.
Those that believe an excess of estrogen (Estrogen Dominance)is the cause of Adenomyosis, or that it aggravates the symptoms, recommend avoiding products with xenoestrogen
Xenoestrogen
Xenoestrogens are a type of xenohormone that imitates estrogen. They are widely used industrial compounds such as PCB, BPA and Phthalates, that have estrogenic effects on a living organism even though they differ chemically from the naturally occurring estrogenic substances internally produced by...
s and/or recommend taking Natural Progesterone Cream which may help balance the hormone levels.
Chinese herbal supplements DIM and Myomin are claimed to reduce excess estrogen, shrink fibroids and reduce significantly the adenomyosis symptoms. DIM is a blend of cruciferous vegetable extracts including broccoli, cauliflower, cabbage and brussel sprouts. Research shows it helps metabolize unhealthy circulating estrogens (estrone, estradiol) into the good form (estriol).
Myomin is an all natural formula of Chinese herbs that has been shown to help metabolize unhealthy estrogens and promote proper hormonal balance. Studies show that it also inhibits aromatase, an enzyme that converts androgens (testosterone) into estrogen.In addition to that, it competes with estradiol at the estrogen receptors of target cells. This is why Myomin is so effective for estrogen-dominant conditions such as cysts and fibroids (International Journal of Integrative Oncology. Mar 2008; 2(1):7-15).
The operation 'Hysterectomy' should only be considered as a very last form of treatment option for this condition once full understanding of the long term effects have been read and understood. See Hysterectomy Education Resources and Services (HERS) website which explains the longer term after effects to having the uterus, cervix and/or ovaries removed.
Other considerations
The differential of abnormal uterine bleeding includes- endometrial polypsPolyp (medicine)A polyp is an abnormal growth of tissue projecting from a mucous membrane. If it is attached to the surface by a narrow elongated stalk, it is said to be pedunculated. If no stalk is present, it is said to be sessile. Polyps are commonly found in the colon, stomach, nose, sinus, urinary bladder...
- submucosal fibroidsLeiomyomaA leiomyoma is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.- Etymology:* Greek:** λεῖος leios "smooth"...
- endometrial hyperplasiaEndometrial hyperplasiaEndometrial hyperplasia is a condition of excessive proliferation of the cells of the endometrium, or inner lining of the uterus.Most cases of endometrial hyperplasia result from high levels of estrogens, combined with insufficient levels of the progesterone-like hormones which ordinarily...
- endometrial carcinoma
Prognosis
It is advocated that adenomyosis poses no increased risk for cancer development. However, since adenomyosis can invade myometrium and is related to adenocarcinoma which can itself be either benign or malignant, there is recent evidence of rare progression of adenomyosis to endometrial carcinoma. As the condition is estrogen-dependent, menopause presents a natural cure. Patients with adenomyosis often also have leiomyomaLeiomyoma
A leiomyoma is a benign smooth muscle neoplasm that is not premalignant. They can occur in any organ, but the most common forms occur in the uterus, small bowel and the esophagus.- Etymology:* Greek:** λεῖος leios "smooth"...
ta and/or endometriosis
Endometriosis
Endometriosis is a gynecological medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones...
.