Classically the disorder appears from the age of 35 into the 40’s and usually presents with significant pain and occasionally irregular and heavy bleeding. It is most likely that the disorder relates to an as yet unidentified abnormality at the endo-myometrial interface (EMI) – and in this respect is similar to endometriosis as is known there are abnormalities in this area also.
Unfortunately the diagnosis is difficult and traditionally has relied on an index of suspicion clinically followed by the finding of a painful (bulky) uterus. Imaging techniques such as ultrasound may reveal irregular areas most usually in the posterior aspect of the uterus although it can at times be difficult to differentiate these from fibroids. Fibroids tend to be more discreet whilst adenomyosis tends to be more generalized although at times there can be isolated areas of adenomateous change within the uterus. More recently MRI has been advanced as a preferred diagnostic option although currently within an Australian context the cost of this has kept it out of main stream usage.
Infertility
Adenomyosis has not been directly linked as a cause of infertility and at least one recent article did not reveal differences in assisted conception cycles although other authors have demonstrated an increased miscarriage rate and decreased take home baby in patients with adenomyosis.There is no reason not to proceed with IVF if you have adenomyosis and many patients are still successful.
Treatment
Treatment is difficult particularly for those wishing to conceive as many of the accepted options are contraceptive. These currently include simple pain relievers and non steroidal anti-inflammatory drugs. For those in whom pregnancy is not a consideration it may be possible to use Mirena, the new progestegin impregnated IUCD (although this at times may exacerbate the situation) or alternatively the oral contraceptive pill to relax the uterus. Many people have successfully conceived with IVF and it Localized resection of an adenomyoma is occasionally suggested although the results are often disappointing. Unfortunately the disorder tends to progress and not uncommonly ultimately results in hysterectomy where the diagnosis is finally formaly made. Hysterectomy in this circumstance should usually be performed laparoscopically so that the peritoneal cavity can be visualized and in particular any endometriosis dealt with at the same time. Vaginal hysterectomy alone is not appropriate in my view for the treatment of pain because of the inability to exclude and deal with endometriosis.
