Adenomyosis

Adenomyosis (pronounced A - den - o - my - os - is) 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.

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 section, 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:
 * Endometrial IL-18 receptor mRNA and the ratio of IL-18 binding protein to IL-18 are significantly increased in adenomyosis patients in comparison to normal people.
 * Leukemia inhibitory factor is dysregulated in the endometrium and uterine flushing fluid of women with adenomyosis during the implantation window.

Diagnosis
The uterus 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.

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 ablation 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 xenoestrogens 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 polyps
 * submucosal fibroids
 * endometrial hyperplasia
 * 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 leiomyomata and/or endometriosis.