Adenomyosis: Clinical sciences

Adenomyosis is a condition characterized by abnormal growth of endometrial glands and stroma into the myometrium, often resulting in an enlarged and globular uterus. Although adenomyosis can occur at any age, it’s most commonly diagnosed in multiparous patients in their 30s and 40s. Diagnosis can be challenging as the symptoms often mimic those of other gynecological conditions, like endometriosis or uterine leiomyomas. Treatment options vary depending on the severity of symptoms and the reproductive goals of the patient.

When a patient presents with a chief concern suggesting adenomyosis, start by obtaining a focused history and physical exam. Commonly reported symptoms include heavy menstrual bleeding, dysmenorrhea, or pain during menstruation, chronic pelvic pain, and possibly dyspareunia, which is pain during intercourse. On physical exam, you may note an enlarged or globular uterus and possibly uterine tenderness. Based on these findings, you can suspect adenomyosis.

The next logical step is to confirm your diagnosis by obtaining some imaging studies. A pelvic ultrasound, incorporating both transvaginal and transabdominal views, is the first choice for identifying adenomyosis. In some situations, like when you need a more detailed look or an ultrasound can’t make the diagnosis, you can consider an MRI.

Alright, characteristic findings on ultrasound include a heterogeneous myometrium with streaky shadowing, asymmetric myometrial thickness, and often you can see myometrial cysts. Sometimes, you will see only some but not all of these findings. In this situation, adenomyosis should be high on your differential, so proceed with this clinical diagnosis.

Here’s a clinical pearl! The gold standard for diagnosis is histological examination of the uterus after hysterectomy. Obviously, this requires loss of the organ, so usually adenomyosis is clinically diagnosed unless hysterectomy is indicated.

Alright, now that we’ve confirmed the diagnosis of adenomyosis, let’s discuss treatment. Management is tailored to the patients' individual goals of therapy, especially taking into account their immediate and long-term reproductive plans. First, assess the patient’s desire for pregnancy. If your patient wants to become pregnant immediately, your first step in treatment is analgesia to address any pain they’re experiencing from adenomyosis. Pain relief can be achieved with oral medications, such as NSAIDs. Be sure to tell them that NSAIDs should be taken only once menses occurs, and preferably after a negative pregnancy test to avoid possible adverse outcomes during early pregnancy.

Next, consider pelvic floor physical therapy, which can aid in strengthening and supporting the pelvic muscles, as many patients with adenomyosis will have coexisting pelvic floor dysfunction and pain. Finally, think about an infertility workup to assess factors that may affect the patient’s ability to conceive and identify underlying issues that require targeted intervention.

Okay, let’s go back a step and talk about patients who express a future desire for pregnancy as well as those who don’t desire pregnancy. In asymptomatic patients or those who do not desire intervention, you can proceed with expectant management. Be sure to continue following these patients and assess their symptoms on a regular basis. On the flip side, if your patient has symptomatic adenomyosis, consider pelvic floor physical therapy to address dysfunction and pain. Now, medical management is appropriate for symptomatic patients who desire intervention. First-line therapy consists of analgesia with NSAIDs. These can be used either alone or with combined oral contraceptive pills. Other first-line treatments include progestins, such as the levonorgestrel intrauterine system or the etonogestrel implant.