Adenomyosis is a common, benign gynecological disease, in which tissue from the lining of the womb (endometrium) is found inside the muscle of the womb (myometrium). It is of unknown aetiology and typically presents with heavy and painful periods. There, also, appears to be a link between adenomyosis and infertility.

How common is adenomyosis?

Although the exact incidence of the disease is not known, it is believed to affect up to 20% of patients visiting the gynecology clinic. It is more common in women in their 40s and those who have had uterine surgeries. It, also, commonly co-exists with other, oestrogen-dependent, gynecological conditions, such as endometriosis and fibroids.

How is adenomyosis diagnosed?

In the (not too distant) past, diagnosis of adenomyosis was achieved by histopathology of the hysterectomy specimen, after the uterus had been removed. With advances in the field of medical imaging, adenomyosis can now be, confidently, diagnosed by non-invasive methods, such as transvaginal ultrasound and magnetic resonance imaging (MRI), based on the presence of certain diagnostic criteria. It is, also, worth noting that there are different types of adenomyosis: focal, diffuse, cystic and solid.

Medical management options:

These include the combined contraceptive pill (oestrogen and progestogen), progestogens delivered via different routes (intra-uterine device/coil, injection, subcutaneous implant) as well as GnRH agonists. A recent, promising group of drugs are the GnRH antagonists that can be delivered orally. Since, as we mentioned earlier, adenomyosis is a hormone-dependent condition, medical management is based on the administration of hormones, with an aim to improve the symptoms of heavy and painful periods, without performing an operation. Albeit often successful, it is not accepted by many patients due to unpleasant side-effects, reluctance to use hormones or immediate pregnancy wish.

Surgical management options:

In women with intense symptoms that have completed child-bearing, laparoscopic hysterectomy (removal of the uterus with preservation of both ovaries) will offer complete relief, particularly so in diffuse adenomyosis. However, many patients may not have completed child- bearing or may not wish to undergo hysterectomy. In such cases, uterus-sparing surgical techniques are best applicable. We recognise 2 basic types: Adenomyomectomy (removal of focal adenomyosis) and cytoreductive surgery (for diffuse adenomyosis). In the first type, we remove the foci of adenomyosis and leave the healthy myometrium behind, whilst, in the second type, large parts of the myometrium may need to be removed at the same time. In the first type, the operation can be performed (in the hands of appropriately trained surgeons) laparoscopically, whilst, in the second type, a laparotomy (open surgery) is often required. In women who have completed child-bearing but do not wish to undergo hysterectomy, alternative, minimally-invasive procedures can be performed (eg. HIFU, radiofrequency ablation etc.).

Adenomyosis and Infertility:

The disease is likely to have a negative impact on the chances of spontaneous conception, 1^st trimester complications, as well as the likelihood of success of various methods of artificial reproductive technology (ART). It, also, appears that the likelihood of pregnancy may further deteriorate as the ‘’severity’’ of adenomyosis (by ultrasound criteria) increases. A link to obstetric complications, such as preterm birth and post-partum haemorrhage appears to exist too.  High-quality, surgical excision of adenomyosis may increase chances of conception. Moreover, the pre-treatment use of GnRH agonists before IVF may increase the chances of success.

In conclusion, adenomyosis remains an enigmatic disease.  Albeit, in the past, it was considered to be a disease of the multiparous women, it is more and more diagnosed in younger women and an association with infertility has become clearer. The decision on the correct management method needs to be highly individualised, based on the primary complaint as well as the fertility wishes of the patient.