What is Adenomyosis and why does it occur?

Adenomyosis is defined as the invasion of the endometrial tissue, which lines the inner surface of the uterus, into the muscular wall of the uterus. Regarding its origin, there are two theories, the most widely accepted is that it occurs as a consequence of a trauma that favors the invagination of endometrial cells in the myometrium or as a consequence of the transformation (metaplasia) of pluripotent cells remaining from embryonic development.

Can Adenomyosis affect fertility?

It has been suggested that it may have an unfavorable effect on fertility due to various symptoms:

• Anatomical alteration of the uterine cavity and the uterotubal junction.

• Disorders of tubal peristalsis and myometrial contractility.

• Alteration of endometrial receptivity, since its presence generates a hyperestrogenic environment and resistance to progesterone (1).

How is Adenomyosis diagnosed?

Diagnosis is histological, that is, by analyzing tissue samples, although imaging techniques, especially MRI and transvaginal ultrasound, allow us to diagnose the condition non-invasively. Recently, the MUSA (Morphological Uterus Sonographic Assessment) group has established a classification system for the different types of Adenomyosis based on ultrasound findings. This has facilitated its diagnostic classification and follow-up, thus limiting the use of other more expensive studies such as MRI.

What percentage of women are affected by Adenomyosis?

Adenomyosis is present in about 20% of women, it is rare in women under 20 years of age, however, there are some rare cases in adolescents. It is more common in multiparous women (women who have given birth more than once) and in the perimenopausal period (first symptoms of menopause). It is estimated according to studies that around a quarter or a third of women with Endometriosis also have Adenomyosis. The delay in choosing to become a mother has increased its prevalence in the population of infertile women, thus 22% of infertile women under 40 years of age have Adenomyosis.

In fact, some authors support screen testing to try to find an early diagnosis in women with unexplained infertility. The negative impact of Adenomyosis on assisted reproductive techniques has also been established, reducing the gestation rate, increasing the miscarriage rate, and reducing the live new-born rate. (2)

What are the symptoms?

The most common symptoms of Adenomyosis are:

• Dysmenorrhea (menstrual pain).
• Menorrhagia (prolonged and heavy menstrual bleeding).
• Chronic pelvic pain.
• Dyspareunia (painful intercourse).

In younger women, it can be suspected in suffers of very severe dysmenorrhea.

Does it have any effects on pregnancy?

The presence of Adenomyosis can affect the normal remodeling of the spiral arteries and therefore have implication in certain obstetric complications such as: delayed intrauterine growth, preterm delivery, pre-eclampsia and obstetric hemorrhage (due to the worse contractile capacity of the myometrium). It can also double the risk of caesarean section.

Uterine rupture is a very serious outcome that occurs in 0.5-3 cases per 10,000, in women who present Adenomyosis and previous uterine surgery, the risk is 4-8%. Given this, the authors recommend the monitoring of pregnant women with Endometriosis and Adenomyosis in high-risk obstetric units (3).

How is Adenomyosis treated?

Various studies support the treatment of this pathology with Gonadotropin (GnRh) analogues, either prior to the use of assisted reproduction techniques or in cryotransfer cycles where the use of analogs improves newborn rates, due to the effect of level of the endometrial microenvironment and the positive impact on endometrial receptivity.

Women who do not wish to have children are treated primarily with anti-inflammatory drugs to control pain, contraceptives, gestagens (gestagens-only pill, levonorgestrel-releasing IUD or dienoges). In very severe cases of diffuse Adenomyosis that do not respond to medical treatment, surgery is proposed, but in no case is it the first choice (4).

Once again it is clear how important it is to find a diagnosis from which we can find the most appropriate treatment to treat pathologies such as Endometriosis or Adenomyoisis. A diagnosis that can also give us the cause of infertility and help us determine which fertility techniques will be the most successful to achieve pregnancy. 

Do not normalize menstrual pain, if there is something that worries you, contact our team and make an appointment now.

References

1. Mavrelos D, Holland TK, ODonovan O, khalil M, Ploumpidis G, Jurkovic D, Khalaf Y. The impact of adenomiosis on the outcoem of IVF_embryo transfer. RBM On line.2017;549-554.
2. Vercellini P, Consoni D, Dridi D, Bracco B, Frattaruolo MP, Somigliana E. Uterine adenomyosis and in vitro fertilization outcome: a systematic review and meta-analysis.Human reprod.2014;29:964-977.
3. Brosens I, Pijnenborg R,Benagiano G. Defective myometrial spiral artery remodeling as a cause of major obstetrical syndromes in endometriosis adenomyosis. Placenta.2013,34.100-105.
4. Li JJ, Chung PW, Wang S, Li T-C, Duan H. The investigation and management of adenomyosis in women who wish to improve or preserve fertility.Biomed Research Int. 2018;1-12.