Thursday, August 26, 2010
Adenomyosis and Infertility
Also known as "Endometriosis of the uterus," adenomyosis ( adeno= glands; myo = muscle) is a benign condition which occurs when the glandular cells of the uterine lining ( the endometrium) penetrate deep into the uterine muscle (myometrium) and invade into it. Adenomyosis used to be called "endometriosis interna," since it can look somewhat like endometriosis under the microscope . However, this occurs within the muscle wall of the uterus, not on pelvic surfaces as does endometriosis.
Most commonly, the disease affects the back wall (posterior side) of the uterus. When this occurs, the uterus is enlarged usually more than twice the normal size and very hard. The disease may be localized with well-defined borders ; or diffuse, meaning it has no limits or borders. When the disease is localized , it is called an adenomyoma. These adenomyomas can be located at different depths of the uterine muscle .
The disease is often under-diagnosed because many doctors do not consider this possibility . Patients who have localized adenomyosis are often misdiagnosed as having fibroids. Others are just labeled as having a “bulky uterus” or DUB ( dysfunctional uterine bleeding). This disease can only be diagnosed with 100% certainty by doing a biopsy of the uterine muscle, a procedure which is done very rarely ! About 10% of women with adenomyosis have also had endometriosis in other sites such as the pelvic wall, ovaries, fallopian tubes etc. The highest incidence is seen in women in their forties, and though this disease may cause infertility, it usually occurs in women who have already had children.
As with Endometriosis, patients with Adenomyosis may not show any symptoms (asymptomatic). However, women most commonly experience excessive, heavy or prolonged menstrual bleeding and painful periods (dysmenorrhea). The amount of bleeding and cramps is usually associated with the degree of disease involvement and depth of penetration into the uterine walls. Extensive involvement of the uterine muscle can also interfere with the normal contractility of the muscle which then leads to excessive bleeding.
An exact diagnosis is often difficult to establish pre-operatively because abnormal patterns of bleeding (dysfunctional bleeding) and fibroid tumors can result in similar symptom patterns. Sometimes during a D&C procedure to remove intra-uterine polyps or small fibroid tumors, uterine tissue is removed , enabling a pathologist to make the tissue diagnosis. However, this is often an incidental finding. Pelvic exam findings can reveal a slightly enlarged uterus . In some women, the uterus is enlarged (upto twice the normal size) and can also be tender and “boggy”. Vaginal ultrasound shows the uterus is enlarged and bulky, but it's difficult to make an accurate diagnosis of adenomyosis with ultrasound, since the density of the invading endometrial tissue may not differ sufficiently from the surrounding uterine muscle wall. Occasionally the uterus may be described as slightly enlarged in a symmetrical fashion, with a fuzzy shadowy pattern seen in the muscle wall. MRI can also be used to distinguish adenomyomas from fibroid tumors.
Since no medicine eradicates adenomyosis, medical treatments are frustrating for patients as well as physicians . Since the uterus is a hormonally responsive organ, hormones are the mainstay of medical treatment of symptoms. Your doctor may prescribe birth control pills or progesterone pills or shots. Although gonadotropin-releasing hormone agonists such as Lupron have been found to reduce uterine symptoms of adenomyosis during treatment, the symptoms return quickly after the medicine wears off. Pain pills, whether over the counter or prescription, can be used to tide the patient over rough spots.
Adenomyosis and infertility
The relationship between adenomyosis and infertility is still very controversial . Many doctors believe that adenomyosis does not reduce fertility, since it affects only the muscle wall of the uterus. This means that the uterine cavity and the uterine lining in these patients are normal, which means their fertility should be normal as well. However, real effect on fertility is virtually impossible to know since it is so difficult to diagnose the disease in women who have an uterus.
If an infertile woman is found to have adenomyosis, we usually do not offer any specific treatment for this diagnosis , as this diagnosis does not affect your treatment options !