Uterine adenomyosis (uterine gland enlargement) Why does it occur and how is it treated

Uterine Adenomyosis (Adenomyosis of the Uterus) is a condition whose symptoms may sometimes be mistaken for normal menstrual pain. However, heavy menstrual bleeding, severe cramps, or persistent pelvic pain may be signs that require medical evaluation. The condition occurs when tissue similar to the lining of the uterus (endometrial tissue) grows into the muscular wall of the uterus, which may cause thickening of the uterine wall and lead to a range of symptoms that vary in severity from one woman to another.What causes uterine adenomyosis? What are its most common symptoms? How is it diagnosed? Can it be treated with medications, or might some cases require surgical intervention?At Dalili Medical, this article explores uterine adenomyosis (adenomyosis of the uterus), including its types, causes, symptoms, diagnostic methods, treatment options, and the most important tips for managing the condition.

What Is Uterine Adenomyosis?

Uterine adenomyosis, also known as adenomyosis of the uterus, is a condition in which tissue similar to the lining of the uterus (endometrium) grows within the muscular wall of the uterus. This may cause the uterine wall to become thicker and the uterus to enlarge, leading to symptoms such as heavy menstrual bleeding and severe menstrual pain.

Is Uterine Adenomyosis the Same as Polycystic Ovary Syndrome?

No. Uterine adenomyosis and polycystic ovary syndrome (PCOS) are two different conditions. Adenomyosis affects the muscular wall of the uterus, whereas PCOS is a hormonal disorder that affects ovarian function and ovulation and may cause irregular menstrual cycles and other symptoms.

Is Adenomyosis the Same as an Ovarian Cyst?

No. These are two different conditions. An ovarian cyst is a fluid-filled sac or cavity that may develop inside or on the surface of an ovary, whereas adenomyosis occurs within the muscular wall of the uterus.

Is Uterine Adenomyosis the Same as an Ectopic Pregnancy?

No. Uterine adenomyosis and ectopic pregnancy are completely different conditions. An ectopic pregnancy occurs when a fertilized egg implants outside the uterine cavity, most commonly in a fallopian tube. Adenomyosis, on the other hand, occurs when tissue similar to the endometrium grows within the muscular wall of the uterus.

Does Uterine Adenomyosis Cause Heavy Menstrual Bleeding?

Yes. Heavy menstrual bleeding is one of the common symptoms of uterine adenomyosis. The bleeding may last longer than usual and, in some cases, may be accompanied by blood clots during menstruation.

Does Uterine Adenomyosis Cause Severe Pain?

Yes. Adenomyosis can cause severe menstrual pain and painful uterine cramps. Some women may also experience persistent or recurrent pelvic pain, including pain outside their menstrual periods.

Is Uterine Adenomyosis Dangerous?

Uterine adenomyosis is a benign condition and is not cancer in itself. However, it can cause bothersome symptoms that affect quality of life, such as severe pain and heavy menstrual bleeding. Repeated blood loss may lead to iron deficiency or anemia if the bleeding is not adequately controlled.

Can Uterine Adenomyosis Be Seen on an Ultrasound?

Yes. Certain signs suggestive of uterine adenomyosis may be detected through ultrasound, such as changes in the thickness or appearance of the uterine wall and the presence of heterogeneous areas or small cystic spaces within the uterine muscle. In some cases, a doctor may recommend magnetic resonance imaging (MRI) to obtain more detailed images, particularly when ultrasound findings are inconclusive.

Does Uterine Adenomyosis Cause an Enlarged Uterus?

Yes. Uterine adenomyosis may cause an increase in uterine size and thickening of the uterine muscle due to the presence of endometrial-like tissue within the muscle. This may be more noticeable in some cases of diffuse adenomyosis.

Does Uterine Adenomyosis Prevent Pregnancy?

Not necessarily. Many women with uterine adenomyosis can become pregnant. However, the condition may be associated with fertility difficulties in some women and may increase certain pregnancy-related risks. Therefore, women who are planning a pregnancy should discuss their condition with an obstetrician-gynecologist to determine the most appropriate management plan.

Does Hysterectomy Cure Uterine Adenomyosis?

Yes. Hysterectomy is considered the definitive surgical treatment for uterine adenomyosis, as it removes the uterus containing the adenomyotic tissue. However, the procedure permanently eliminates the ability to become pregnant and is therefore not suitable for women who wish to preserve their fertility.

Can Uterine Adenomyosis Return After Treatment?

The possibility of symptom recurrence depends on the type of treatment used. Symptoms may return after stopping certain medications because these treatments generally aim to control symptoms and reduce disease activity rather than permanently remove adenomyosis.

After hysterectomy, adenomyosis cannot recur in the uterus that has been removed. However, some adenomyotic tissue may remain, or symptoms may recur after uterus-preserving procedures, depending on the extent of the condition and the type of procedure performed.

Can Uterine Adenomyosis Turn Into Cancer?

Uterine adenomyosis is a benign condition and is not cancer itself, nor is it considered a type of uterine cancer. However, any new or unusual uterine bleeding or a significant change in the usual bleeding pattern should be evaluated by a gynecologist to determine the cause and rule out other conditions that may require treatment.

Does Uterine Adenomyosis Disappear After Menopause?

The symptoms of uterine adenomyosis usually improve after menopause because hormone levels that influence endometrial-like tissue decline. The size of the uterus and the changes associated with adenomyosis may also decrease over time. However, this does not necessarily happen immediately, and the degree of improvement varies from one woman to another.

Types of Uterine Adenomyosis

Uterine adenomyosis (Adenomyosis) can be classified in several ways according to the location, extent, and appearance of the changes on imaging studies. There is no single universally accepted classification system, so the terminology used may vary between physicians and radiology reports.

1. Diffuse Uterine Adenomyosis

This type occurs when adenomyotic tissue is distributed throughout a large area of the uterine muscle, rather than being concentrated in a specific location.

It may be associated with:

Thickening of the uterine wall.
An enlarged uterus.
Heavy menstrual bleeding.
More severe menstrual pain and cramps.
A feeling of pelvic heaviness or pain.

2. Focal Uterine Adenomyosis

In focal adenomyosis, the changes are concentrated in a specific area of the uterine muscle, rather than being distributed throughout a large portion of the muscle.

The affected area may appear on imaging studies, such as ultrasound or MRI, as an abnormal region within the uterine muscle.

3. Adenomyoma

An adenomyoma is a localized form of adenomyosis in which adenomyotic tissue and smooth muscle are concentrated in a specific area, forming a mass within the uterine wall.

Its appearance may resemble that of a uterine fibroid in some cases. Therefore, distinguishing between the two depends on the clinical examination and imaging characteristics.

4. Internal and External Adenomyosis

Different anatomical descriptions may be used to indicate the location of adenomyosis within the uterine wall, including:

Internal adenomyosis:
Refers to changes located near the area where the endometrium meets the uterine muscle.

External adenomyosis:
Refers to changes located closer to the outer surface of the uterine muscle.

These descriptions help determine the location and extent of the changes and do not necessarily indicate a specific difference in symptoms between cases.

5. Classification According to Extent and Severity

A physician may describe adenomyosis as limited or more extensive and may use different grades to describe its severity, based on imaging findings and the extent to which the uterine muscle is affected.

However, disease severity should not be determined by imaging findings alone. The patient's symptoms and their impact on daily life should also be taken into consideration when evaluating the condition and developing a treatment plan.

Causes of Uterine Adenomyosis

The exact cause of uterine adenomyosis remains unclear. Several theories have been proposed to explain how the condition develops.

1. Invasion of Endometrial Tissue Into the Uterine Muscle

This is one of the main theories explaining adenomyosis. It suggests that tissue from the endometrium may invade the muscular layer of the uterine wall.

This tissue responds to hormonal changes that occur during the menstrual cycle, which may lead to local inflammation and changes within the uterine muscle, resulting in thickening and enlargement of the uterine wall.

2. Changes in the Junction Between the Endometrium and Uterine Muscle

There is a transitional area between the endometrium and the uterine muscle known as the junctional zone. One theory suggests that damage or abnormalities in this area may contribute to the movement of endometrial tissue into the uterine muscle.

Certain previous uterine procedures or surgeries have been associated with an increased likelihood of adenomyosis, including:

Cesarean section.
Certain uterine surgeries.
Fibroid removal (myomectomy).
Some medical procedures involving intervention inside the uterus.

However, having a history of previous uterine surgery does not necessarily mean that the procedure was the direct cause of adenomyosis.

3. The Role of Hormones

Uterine adenomyosis is influenced by hormonal changes, particularly estrogen and progesterone, which is why the condition is more commonly seen during the reproductive years.

The symptoms of adenomyosis may improve after menopause as hormonal activity decreases, supporting the possible relationship between hormones and disease activity.

4. Healing of Uterine Tissue After Pregnancy or Surgery

One theory suggests that the healing and repair of uterine tissue after pregnancy or certain surgical procedures may cause changes in the junctional zone between the endometrium and the uterine muscle.

According to this theory, these changes may facilitate the invasion of endometrial-like tissue into the uterine muscle.

5. Development of Endometrial-Like Cells Within the Uterine Muscle

Another theory proposes that some cells resembling endometrial cells may already be present within the uterine muscle from the early development of the uterus and may become active later under the influence of hormones during the reproductive years.

This hypothesis is still being investigated.

6. The Role of Stem Cells

Some recent research suggests that stem cells or progenitor cells within the uterus may play a role in the development of adenomyosis.

According to this theory, some of these cells may develop into endometrial-like tissue within the uterine muscle. However, the exact mechanism remains incompletely understood.

Factors That May Increase the Risk of Uterine Adenomyosis

In addition to the theories regarding how the condition develops, certain factors have been associated with an increased likelihood of adenomyosis, including:

Age during the reproductive years, particularly during the middle or later reproductive years.
Previous pregnancy and childbirth.
A history of uterine surgery or procedures, such as cesarean delivery or certain uterine surgeries.
The presence of other gynecological conditions, such as endometriosis and uterine fibroids.

Can the Exact Cause of Adenomyosis Be Determined in Every Case?

In most cases, a single definite cause cannot be identified. Adenomyosis is thought to result from an interaction of several factors, including hormonal changes and changes in uterine tissues, along with other factors that are still being investigated.

Therefore, having one or more risk factors does not necessarily mean that a woman will develop adenomyosis, while the absence of these factors does not rule out the condition.

Symptoms of Uterine Adenomyosis

Symptoms of uterine adenomyosis vary from one woman to another. Some women may have no noticeable symptoms, while others may experience severe and persistent symptoms that affect their daily lives.

1. Heavy Menstrual Bleeding

Heavy menstrual bleeding is one of the most common symptoms of uterine adenomyosis. The amount of menstrual blood may become greater than usual, or bleeding may last longer.

A woman may notice:

A significant increase in menstrual blood flow.
The need to change sanitary products frequently.
Menstrual bleeding that lasts for more days than usual.
Blood clots during menstruation in some cases.

2. Severe Menstrual Pain

Adenomyosis may cause dysmenorrhea, resulting in strong cramps and pain in the lower abdomen and pelvic area during menstruation.

In some women, menstrual pain may gradually become more severe over time and may not respond as effectively to usual pain relievers.

3. Chronic or Recurrent Pelvic Pain

Some women may experience pelvic pain outside their menstrual periods. The pain may be persistent or may come and go over time.

It may extend to the lower abdomen or back, and its severity varies from one case to another.

4. A Feeling of Heaviness or Pressure in the Lower Abdomen

A woman may experience heaviness or pressure in the pelvic area or lower abdomen, particularly when adenomyosis causes the uterus to enlarge.

5. Pain During Sexual Intercourse

Adenomyosis may cause pain during sexual intercourse in some women. The pain may become more noticeable during certain phases of the menstrual cycle.

6. Prolonged Menstrual Periods

Menstrual bleeding may continue for longer than usual, often in association with heavy menstrual bleeding.

7. Bleeding or Spotting Between Periods

Some women may experience abnormal uterine bleeding or spotting between menstrual periods. However, bleeding between periods can have many different causes and should be medically evaluated to determine the underlying cause.

8. Enlarged Uterus

Adenomyosis may cause an increase in uterine size and thickening of the uterine muscle. A doctor may detect an enlarged uterus during a pelvic examination, while changes associated with adenomyosis may also be visible on ultrasound or magnetic resonance imaging (MRI).

9. Bloating or a Feeling of Fullness in the Pelvic Area

Some women may experience bloating, fullness, or heaviness in the lower abdomen. These sensations may be more noticeable when the uterus is enlarged.

10. Fatigue and Exhaustion

When menstrual bleeding is heavy and recurrent over a long period, blood loss may lead to iron deficiency or anemia, which can cause symptoms such as:

Fatigue and exhaustion.
General weakness.
Dizziness.
Headaches.
Pale skin.
Shortness of breath, particularly during physical activity.

Medical Treatment for Uterine Adenomyosis

Treatment of uterine adenomyosis with medications depends on the nature and severity of the symptoms, particularly menstrual pain and heavy bleeding. The patient's age, general health, and plans for future pregnancy are also taken into consideration.

There is no single medication that permanently eliminates adenomyosis in all cases. However, medications can help relieve pain, reduce bleeding, control symptoms, and improve quality of life.

1. Pain Relievers and Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to help relieve menstrual pain and cramps associated with adenomyosis.

Examples include:

Ibuprofen.
Naproxen.
Other medications from the same group, according to the doctor's assessment.

These medications may be more effective when taken at the beginning of pain or around the start of the menstrual period, according to medical advice or the medication instructions.

Their suitability should be assessed before use, particularly in women with a history of stomach ulcers or gastrointestinal bleeding, kidney disease, allergies to these medications, or use of other medications that may interact with them.

2. Hormonal Contraceptives

Hormonal contraceptives may help control some symptoms of adenomyosis, particularly heavy menstrual bleeding and menstrual pain.

Available options include certain types of:

Combined oral contraceptive pills containing estrogen and progestin.
Progestin-only contraceptive methods.

These methods may help reduce bleeding, regulate menstrual patterns, or relieve pain.

Not all hormonal methods are suitable for every woman. Therefore, the doctor determines the most appropriate option based on the patient's medical history, risk factors, and pregnancy plans.

3. Progestin Medications

Progestins may be used to treat symptoms of adenomyosis in some women. They can help reduce the hormonal stimulation of the endometrium and related tissues.

They may help:

Reduce heavy menstrual bleeding.
Relieve menstrual pain.
Reduce the activity of adenomyotic tissue.

The type of medication and method of administration vary from one case to another and should be determined by the doctor based on the symptoms and overall health.

4. Hormonal Intrauterine Device (IUD)

The levonorgestrel-releasing intrauterine device (LNG-IUD) is an important hormonal option for controlling symptoms of adenomyosis, particularly heavy menstrual bleeding and menstrual pain.

The IUD is inserted into the uterus by a qualified healthcare professional. Over time, it can significantly reduce menstrual blood loss, and some users may experience very light periods or no periods at all.

5. Tranexamic Acid

When the main problem is heavy menstrual bleeding, a doctor may prescribe tranexamic acid to help reduce the amount of blood lost during menstruation.

It is important to understand that tranexamic acid does not treat adenomyosis itself; rather, it helps control excessive bleeding.

It should not be used without medical advice, particularly in women with a history of blood clots or factors that may increase the risk of thrombosis.

6. Medications That Suppress Hormonal Activity

In some cases where symptoms do not respond adequately to conventional treatments, the doctor may prescribe medications that affect the hormones responsible for stimulating adenomyosis tissue. These may include certain gonadotropin-releasing hormone (GnRH) agonists or antagonists.

These medications may help to:

Reduce menstrual bleeding.
Relieve pain.
Temporarily reduce the activity and size of adenomyosis in some cases.

However, these medications may cause symptoms associated with low estrogen levels. Therefore, they are generally used for a limited period and under medical supervision. In some cases, the doctor may prescribe add-back hormonal therapy to help reduce side effects.

7. Treatment of Iron Deficiency and Anemia

Persistent heavy menstrual bleeding can lead to iron deficiency or anemia.

If tests confirm iron deficiency, the doctor may prescribe iron supplements or another appropriate treatment depending on the severity of the condition.

It is important to emphasize that treating iron deficiency addresses the consequence of blood loss rather than treating adenomyosis itself. Therefore, the underlying cause of the bleeding should also be addressed and appropriately controlled.

Can Adenomyosis Be Permanently Treated With Medication?

Medications are primarily intended to control symptoms and improve quality of life and are not considered a definitive cure for adenomyosis in all cases. Symptoms may return after some treatments are discontinued because these therapies generally aim to control symptoms and reduce disease activity rather than permanently remove adenomyosis.

If severe symptoms persist despite medical treatment, other treatment options may be considered, including interventional or surgical procedures, while taking the woman’s desire to preserve the uterus and fertility into account.

Surgical and Interventional Treatment of Uterine Adenomyosis

Surgical or interventional treatment for uterine adenomyosis may be considered when symptoms are severe or persistent despite medical treatment, when the disease is localized and can be specifically targeted, or when the woman does not wish to become pregnant in the future.

The choice of procedure depends on several factors, including the extent and location of adenomyosis, severity of symptoms, uterine size, overall health, and the woman’s desire to preserve the uterus and fertility.

1. Hysterectomy

Hysterectomy is the most definitive surgical treatment for uterine adenomyosis. It is generally considered for women who do not wish to become pregnant in the future, particularly when severe symptoms persist despite other treatments.

Types of Hysterectomy

Hysterectomy can be performed in several ways, and the most appropriate approach depends on uterine size, overall health, and previous surgical history:

Laparoscopic hysterectomy: The uterus is removed through small abdominal incisions using a camera and specialized surgical instruments.
Abdominal hysterectomy: The uterus is removed through an incision in the abdomen. This approach may be appropriate in certain situations, such as when the uterus is significantly enlarged or other surgical factors are present.
Vaginal hysterectomy: The uterus is removed through the vagina when the patient’s condition is suitable for this approach.

The extent of the procedure may vary from one case to another, such as whether the cervix is removed or preserved. Removal of the ovaries is not inherently required to treat adenomyosis, and the decision regarding the ovaries is made separately based on the woman’s age, health status, and other factors.

Main advantage: Removing the uterus eliminates the site containing the adenomyosis, making hysterectomy a definitive treatment for the condition.

Main consequence: Pregnancy is no longer possible after hysterectomy.

2. Focal Adenomyomectomy

When adenomyosis is localized or focal, it may be possible in selected cases to remove the affected tissue while preserving the uterus.

This procedure is known as adenomyomectomy and may be considered for some women who wish to preserve their uterus and fertility.

How Is the Procedure Performed?

The surgeon identifies the affected area within the uterine muscle and generally:

Accesses the uterus using the appropriate surgical approach.
Removes as much of the affected portion of the uterine muscle as possible.
Carefully reconstructs and sutures the uterine wall.
Follows up with the patient after surgery and evaluates the uterus according to the individual case.

This procedure can be more technically challenging than fibroid removal in some cases because adenomyosis may not have clearly defined boundaries separating it from healthy uterine muscle.

Advantage: It preserves the uterus and may be appropriate for some women who wish to preserve the possibility of pregnancy.

Limitations: It is not suitable for all cases, and some adenomyosis lesions may remain or symptoms may recur later.

Pregnancy following this type of surgery requires careful evaluation and monitoring by a gynecologist, because the procedure involves surgery on the uterine muscle.

3. Endometrial Ablation

Endometrial ablation is a procedure intended to remove or partially destroy the uterine lining in order to reduce heavy uterine bleeding.

It is important to distinguish between the endometrium, which is the inner lining of the uterus, and adenomyosis, in which abnormal endometrial-like tissue is located within the uterine muscle.

Therefore, endometrial ablation may help reduce bleeding in some cases, but it does not directly treat adenomyosis within the uterine muscle. Its effectiveness may be limited, particularly when adenomyosis is deep or extensive.

This procedure is also not recommended for women who plan to become pregnant in the future. Its suitability should be discussed with an obstetrician-gynecologist.

4. Uterine Artery Embolization (UAE)

Uterine artery embolization (UAE) is an interventional procedure in which blood flow to parts of the uterus is reduced using special materials delivered through the blood vessels.

The procedure may help to:

Reduce heavy menstrual bleeding.
Relieve some symptoms associated with uterine adenomyosis.
Reduce the need for hysterectomy in some cases.

However, its effects on fertility and the possibility of future pregnancy require careful evaluation and discussion with a specialist. Therefore, it may not be the first choice for women who wish to become pregnant.

5. Magnetic Resonance-Guided Focused Ultrasound (MRgFUS)

Magnetic resonance-guided focused ultrasound (MRgFUS) is a non-invasive treatment technique that uses focused ultrasound waves to heat targeted areas of affected tissue under MRI guidance.

The aim is to destroy or damage the targeted tissue and reduce its activity and associated symptoms without conventional surgery.

However, the availability of this technique and the expertise required to perform it vary between medical centers. Its suitability also depends on the location, characteristics, and extent of adenomyosis. Therefore, a doctor must assess whether it is appropriate for each individual case.

6. Uterus-Preserving Procedures

Several surgical and interventional procedures have been studied for the treatment of uterine adenomyosis while preserving the uterus, particularly in women who wish to maintain the possibility of future pregnancy.

The choice of the most appropriate procedure depends on several factors, including:

Whether the adenomyosis is focal or diffuse.
The depth of involvement within the uterine muscle.
Uterine size and degree of enlargement.
Severity of symptoms and their impact on daily life.
The presence of other gynecological conditions, such as endometriosis or uterine fibroids.
The woman’s desire for future pregnancy.
Response to previous medical treatments.

Tips for Preventing Uterine Adenomyosis

At present, there is no proven way to completely prevent uterine adenomyosis, largely because the exact cause of the condition remains unknown. Therefore, prevention mainly focuses on maintaining reproductive health, monitoring for abnormal changes in the menstrual cycle, detecting symptoms early, and reducing potential complications such as anemia caused by heavy bleeding.

Regular Follow-Up With an Obstetrician-Gynecologist

Regular medical follow-up is important, particularly when unusually heavy menstrual bleeding or severe and recurrent menstrual pain occurs.

Early evaluation can help identify the cause of symptoms and allow appropriate treatment to begin before symptoms become more severe or interfere with daily life.

Do Not Ignore Heavy Menstrual Bleeding

If menstrual periods become heavier or last longer than usual, it is advisable to consult an obstetrician-gynecologist to determine the underlying cause.

Heavy menstrual bleeding may be associated with uterine adenomyosis, but it can also result from other conditions, such as uterine fibroids or certain disorders of the uterine lining.

Pay Attention to Unusual Menstrual Pain

Severe or progressively worsening menstrual pain should not always be considered normal.

Medical evaluation is recommended if the pain becomes severe, progressively worsens, occurs repeatedly, or interferes with school, work, or daily activities. It may be associated with adenomyosis or another gynecological condition requiring evaluation.

Treat Iron Deficiency When Heavy Bleeding Occurs

Heavy or recurrent menstrual bleeding can lead to iron deficiency and anemia.

Therefore, a doctor may order a complete blood count and iron studies when appropriate, followed by suitable treatment based on the test results and severity of the deficiency.

Inform Your Doctor About Previous Uterine Surgeries and Procedures

When visiting an obstetrician-gynecologist, it is important to inform the doctor about any previous surgeries or procedures involving the uterus, such as cesarean delivery or certain uterine surgeries.

This is because some previous uterine procedures have been associated with an increased likelihood of adenomyosis. However, having a history of a previous procedure does not necessarily mean that it was the direct cause of the condition.

Avoid Using Medications or Hormonal Treatments Without Medical Advice

Some medications and hormonal treatments may help control symptoms of uterine adenomyosis, but the appropriate treatment depends on the symptoms, overall health, and future pregnancy plans.

Therefore, hormonal medications or treatments for heavy bleeding should not be used without proper medical evaluation.