Adenomyosis

Question 1

What is adenomyosis?

Answer 1

Endometrial tissue inside the myometrium (muscle layer of the uterus).

Question 2

Whose most likely to get adenomyosis?

Answer 2

More common in later reproductive years

More common if several pregnancies (multiparous)

Question 3

What is the overall incidence of adenomyosis?

Answer 3

10%

Question 4

What is thought to cause adenomyosis?

Answer 4

The cause is not fully understood, and multiple factors are involved, including sex hormones, trauma and inflammation. The condition is hormone-dependent, and symptoms tend to resolve after menopause, similarly to endometriosis and fibroids.

Question 5

What are symptoms of adenomyosis?

Answer 5

1. Dysmenorrhoea
2. Menorrhagia
3. Dyspareunia
4. Infertility or pregnancy-related complications

Question 6

In adenomyosis, what might examination reveal?

Answer 6

Enlarged and tender uterus (more soft than a uterus containing fibroids).

Question 7

What is the first-line investigation for suspected adenomyosis?

Answer 7

Transvaginal ultrasound of the pelvis.

Question 8

What are alternative investigation options for adenomyosis when transvaginal ultrasound is unsuitable?

Answer 8

1. MRI

2. Transabdominal ultrasound

Question 9

What is the gold standard for adenomyosis diagnosis?

Answer 9

Perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Question 10

To treat adenomyosis, what options are available if women do not want contraception?

Answer 10

Treatment can be used during menstruation for symptomatic relief, with:

1. Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding)
2. Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain)

Question 11

What is the management of adenomyosis when contraception is wanted or acceptable?

Answer 11

1. Mirena coil (first line)
2. Combined oral contraceptive pill
3. Cyclical oral progestogens

Progesterone only medications such as the pill, implant or depot injection may also be helpful.

Question 12

What other options for treating adenomyosis might be considered by a specialist?

Answer 12

1. GnRH analogues to induce a menopause-like state
2. Endometrial ablation
3. Uterine artery embolisation
4. Hysterectomy

Question 13

What pregnancy-related complications are linked with adenomyosis (8)?

Answer 13

1. Infertility
2. Miscarriage
3. Preterm birth
4. Small for gestational age
5. Preterm premature rupture of membranes
6. Malpresentation
7. Need for caesarean section
8. Postpartum haemorrhage