"Ask Dr. Cook" is a series of questions and answers regarding endometriosis. The current subject and answer can be found on Current Ask Dr. Cook web page. The questions may represent a summary of questions I have been asked by several different patients. I hope you find this information helpful. If you have a question you would like answered, please Submit A Question.

Diagnosis and Treatment of Adenomyosis

Question:
Dr. Cook, a friend of mine was talking about a myomectomy for adenomyosis.... to me that is just not logical...... if they remove part of the uterus in order to remove the adenomyosis...#1 who's to say they got it all and #2 if the uterus can no longer function to have children what's the point in keeping it? I mean it doesn't produce hormones...but with doctors in the past doing Hysts left and right is that a valid reason to keep a diseased organ?

Answer:
This is a good example of a situation that can have different correct answers dependent upon the patients circumstances and personal philosophy. To make the correct decision the patient must have a good understanding of her situation and the pros and cons of the various treatment alternatives. With that in mind lets start with a few definitions.

The shape of the uterus is similar to an upside down pair (the stem would be coming out of the cervix in this example). Most of the uterus is made up of smooth muscle. It's job is to hold the baby during pregnancy and to push the baby out during delivery. The inside of the uterus is lined by a thin layer of glands, called the endometrium, similar to the Teflon lining on cookware. During pregnancy, the embryo implants into the endometrium, which provides the necessary nutrients to the developing embryo until the placenta (afterbirth) develops. The endometrium thickens up in response to estrogen secretion the first two weeks of the menstrual cycle. After ovulation the primary hormone production of the ovaries changes from estrogen to progesterone. Progesterone helps to stabilize the endometrium and ready it for implantation. If pregnancy does not occur, both the estrogen and progesterone production drop and the endometrium is shed as the woman has her menses.

Endometriosis is a condition where endometrial tissue is found outside of the uterus. Adenomyosis is defined as endometriosis within the muscle wall of the uterus. Many years ago endometriosis was known as endometriosis exteri (external to the uterus) and adenomyosis was known as endometriosis interi (inside of the uterus). Adenomyosis is usually a result of the endometrium invading into the muscle wall of the uterus. The adenomyosis is usually not a discrete lesion, but often sends out a diffuse network of branching endometrial glands extending from the endometrium throughout the muscle wall of the uterus. There is no real beginning and end of these lesions. If a cross-section of a uterus with adenomyosis is examined, one will see varying concentrations of endometriosis with in the muscle. An area with a high concentration of endometriosis and little remaining muscle tissue is known as an adenomyoma. A fibroid, also known as a leiomyoma, is a smooth muscle tumor in the wall of the uterus. When removed fibroids have a look similar to a rubber ball. There is a definite beginning and end to a fibroid.

The most common symptoms of patients with adenomyosis are painful periods with a very heavy flow and potentially anemia (low blood count) as a result. A normal uterus is fairly hard and firm. A uterus with adenomyosis is usually slightly enlarged and is soft or squishy to the feel. A careful history and physical exam should raise the possibility of adenomyosis. A sonogram (ultrasound) and laparoscopic evaluation may also be helpful in making the diagnosis. Newer generation MRI's can often identify adenomyosis. Examination of the surgical specimen under a microscope is the only method to make an absolute diagnosis of adenomyosis.

The treatment options for adenomyosis are similar to those of endometriosis:

1.  Observation is an acceptable option if the symptoms are not severe.

2.  Medical treatment includes birth control pills and GnRH agonists such as Lupron or Synarel. The pills will lighten the period and thus symptoms. The GnRH agonists will temporarily alleviate the symptoms and reduce the size of the adenomyosis. They will not eliminate the adenomyosis nor prevent continued growth once the GnRH is discontinued.

3.  Conservative surgical treatment with preservation of the uterus. It is impossible to remove all of the adenomyosis and preserve the uterus. Removal of fibroids (a different condition from adenomyosis) and reconstruction of the uterus during a myomectomy is successful because fibroids are discrete lesions which can be completely removed. Small microscopic fibroid "seedlets" can remain and are one reason fibroids can recur after a myomectomy. If fibroids do recur after a myomectomy, it is usually many years later. In contrast the adenomyosis is so diffuse that an adenomyomectomy (removal of the adenomyosis with reconstruction of the uterus) will reduced the amount of adenomyosis present but by the nature of the lesion a significant amount usually remains in the uterus. Chances are, the patient will need to undergo additional surgery within a couple of years. A woman who is trying to get pregnant or the unusual case with a single well defined adenomyoma may be candidates for conservative surgical treatment. Conservative surgical treatment may also be an acceptable option for a woman who philosophically does not want a hysterectomy and does not mind undergoing repeated surgeries to maintain what is admittedly a diseased organ.

4. Definitive surgical treatment with hysterectomy. This is the only option to truly remove or cure the patient of this medical problem. A patient with adenomyosis can also have endometriosis. If endometriosis is present it should be treated prior to actually removing the uterus. The ovaries are responsible for hormone production and will continue to do so after a hysterectomy. Having a hysterectomy is never a decision which should be taken lightly. Too many hysterectomies have been performed in the past, but others wrongs should not influence or prevent you from doing what is right for you. This is a medical condition which, if symptomatic, will usually require the removal of a diseased organ (hysterectomy) to obtain relief from the symptoms while avoiding the real possibility of repetitive surgeries.

Updatede October 29, 2005