ENDOMETRIOSIS AND ADENOMYOSIS
Endometriosis is a disorder in which tissue similar to the tissue that forms the lining of the uterus grows outside of the uterine cavity. The lining of the uterus is called the endometrium.
Endometriosis occurs when endometrial tissue grows on the ovaries, bowel, and tissues lining the pelvis. It might be unusual for endometrial tissue to spread beyond the pelvic region, but it's not impossible. Endometrial tissue growing outside of the uterus is known as an endometrial implant.
The hormonal changes of a person's menstrual cycle affect the misplaced endometrial tissue, causing the area to become inflamed and painful. This suggests that the tissue will grow, thicken, and break down. Over time, the tissue that has broken down has nowhere to go and becomes trapped in the pelvis.
Tissue trapped in the pelvis can cause:
- Scar formation
- Irritation
- Adhesions, in which tissue might bind pelvic organs together
- Severe pain during menstrual periods
- Fertility problems
Endometriosis is a common gynecological condition that affects up to 10 percent of women, therefore, one is not alone if she has this disorder.
Adenomyosis
Adenomyosis occurs when the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus itself. The displaced tissue continues to act normally, (thickening, breaking down and bleeding), during each menstrual cycle. This can result in an enlarged uterus and painful, heavy periods.
Doctors are not sure what causes Adenomyosis, but the disease usually resolves after menopause. For women who have severe discomfort from Adenomyosis, hormonal treatments helps a lot. Hysterectomy (the removal of the uterus) cures Adenomyosis.
AN OVERVIEW
Both adenomyosis and endometriosis are disorders of the endometrial tissue that lines the cavity of the uterus. But they develop differently and have some different symptoms.
In adenomyosis, endometrial cells grow within the wall of the uterus. The misplaced cells follow the menstrual cycle, bleeding monthly.
The uterus wall thickens, and may cause pain and heavy bleeding. It affects older women usually. It has recently been associated with infertility.
In endometriosis, the endometrial cells establish themselves but outside the uterus.
The tissue is commonly found on the ovaries, supporting ligaments of the uterus, and in the cavities of the pelvis. There they also follow the menstrual cycle, and bleed monthly.
This may cause pain and may affect fertility. Unlike adenomyosis, this usually occurs with adolescents and women of reproductive age.
A woman can have one or even both of these disorders. A recent study reveals that 42.3 percent of women with adenomyosis also had endometriosis.
Both are progressive disorders and both are dependent on estrogen.
CAUSES
The cause of Adenomyosis isn't known however there have been many theories including:
- Invasive tissue growth. Some of the experts believe that endometrial cells from the lining of the uterus invade the muscle that forms the uterine walls. Incisions made in the uterine during an operation such as a cesarean section (C-section) might promote the direct invasion of the endometrial cells into the wall of the uterus.
- Developmental origins. Other experts suspect that some endometrial tissue is deposited in the uterine muscle when the uterus is first formed in the fetus.
- Uterine inflammation related to childbirth. There is yet another theory that suggests a link between adenomyosis and childbirth. That the inflammation of the uterine lining during the post natal period might cause a break in the normal boundary of cells that line the uterus.
- Stem cell origins. A recent theory proposes that bone marrow stem cells might invade the uterine muscle, causing adenomyosis.
Regardless of how adenomyosis develops, it has been established that its growth depends on the body's circulating estrogen.
Causes of endometriosis - During a regular menstrual cycle, the body sheds the lining of the uterus. This allows menstrual blood to flow from the uterus through the small opening in the cervix and out through the vagina.
The exact cause of endometriosis isn't known, again there are several theories regarding the cause, yet no one theory has been scientifically proven.
- One of the oldest theories is that endometriosis occurs due to a process called retrograde menstruation, when menstrual blood flows back through the fallopian tubes into the pelvic cavity instead of leaving the body through the vagina.
- Another theory is that hormones transform the cells outside the uterus into cells that are similar to those lining the inside of the uterus, known as endometrial cells.
- Others believe the condition may occur if small areas of the abdomen convert into endometrial tissue. This may happen because cells in the abdomen grow from embryonic cells. These can change shape and act like endometrial cells. It's not known why this occurs. These displaced endometrial cells may be on the pelvic walls and the surfaces of pelvic organs, such as the bladder, ovaries, and rectum. They grow, thicken, and bleed over the course of the host's menstrual cycle in response to the hormones of that cycle. It's also possible that the menstrual blood can leak into the pelvic cavity through a surgical scar, such as after a cesarean delivery (commonly called a C-section).
- Another theory is that the endometrial cells are transported out of the uterus through the lymphatic system.
- Still another theory purports it may be due to a faulty immune system that isn't destroying errant endometrial cells.
- Some others believe that endometriosis might start in the fetal period with misplaced cell tissue that begins to respond to the hormones of puberty. This is referred to as Mullerian theory.
- The development of endometriosis might also be linked to genetics or even environmental toxins.
SIMILARITIES AND DIFFERENCES IN SYMPTOMS
Symptoms of Adenomyosis and endometriosis, typically includes pain, and ranges from mild to severe. Some women with endometriosis however have no symptoms. Actually about a third of all women who have Adenomyosis have no symptoms.
Some symptoms can be similar to those caused by other disorders, such as ovarian cysts or uterine fibroids.
Typical symptoms are as follows:
Adenomyosis
- Metrorrhagia (Abnormal bleeding), or prolonged periods
- Dysmenorrhea (Painful menstrual periods)
- Dyspareunia (Painful sexual intercourse)
- Chronic pelvic pain
- Infertility
- An enlarged uterus
Endometriosis
- Dysuria (painful urination)
- Dysmenorrhea (painful periods)
- Dyspareunia (painful sexual intercourse)
- Dyschezia (painful bowel movements)
- Pelvic pain
- Fatigue, nausea, and diarrhea (especially during menstruation)
RISK FACTORS
Risk factors for Endometriosis
Endometriosis usually develops years after the start of a person's menstrual cycle. This condition can be painful but understanding the risk factors can help to determine whether one is susceptible to this condition and when the person should talk to her doctor.
Age
Women of all ages are at risk for endometriosis, though it usually affects women between the ages of 25 and 40. But symptoms can begin at puberty.
Family history
Talk to a doctor if a woman has a family member who has endometriosis. She may have a high risk of developing the disease.
Pregnancy history
Pregnancy may temporarily reduce the symptoms and effects of endometriosis. Women who haven't had children run a greater risk of developing the disorder. However, endometriosis can still occur in women who've had children. In a way, this supports the understanding that hormones influence the development and progress of endometriosis.
Menstrual history
Women should endeavor to talk to their doctors if they have problems regarding menstrual periods. Issues like shorter cycles, heavier and longer periods, or menstruation that starts at a young age, are factors that may place one at higher risk.
Risk factors for Adenomyosis
Higher risk for adenomyosis is associated with:
- Women who've had more than one child
- Depression and higher use of antidepressants
- Women who are treated with tamoxifen for breast cancer
- Women who've had surgery of the uterus (e.g. dilation and curettage)
DIAGNOSIS
DIAGNOSING ENDOMETRIOSIS
The symptoms of endometriosis can be similar to the symptoms of other conditions, such as ovarian cysts and pelvic inflammatory disease. Treating the pain will require an accurate diagnosis.
The doctor will perform one or more of the following tests:
Ultrasound
The doctor may use a transvaginal ultrasound or an abdominal ultrasound. In a transvaginal ultrasound, a transducer is inserted into the vagina. Both types of ultrasound provide images of the reproductive organs. They can help the doctor identify cysts associated with endometriosis, however, this isn't effective in ruling out the disease.
Laparoscopy
This is the only certain method for identifying endometriosis. This minor surgical procedure known as a laparoscopy views it directly. Once diagnosed, the tissue can be removed in the same procedure
Detailed history
The doctor will note the symptoms and personal or family history of endometriosis. A general health assessment may also be performed to determine if there are any other signs of a long-term disorder.
Physical exam
During a pelvic exam, the doctor will manually feel the abdomen for cysts or scars behind the uterus.
DIAGNOSING ADENOMYOSIS
Adenomyosis can be difficult to diagnose. In the past, it was diagnosed only by examining tissue samples (e.g. after uterine surgery).
Now the noninvasive diagnostic tools of sonograms and MRI are available.
Since adenomyosis causes the uterus to enlarge, the doctor will perform a physical exam to feel if the uterus is swollen or tender.
A sonogram is usually done first. An MRI is used if need be, to confirm the diagnosis.
In cases where a more precise image is required, Sono-hysterography may be used. This involves an injection of saline solution into the uterine cavity before a sonogram.
The Sono-hysterography can distinguish between adenomyosis and other disorders of the uterus such as polyps or cysts, as it allows the inside of the uterus to be better visualized.
TREATMENT
Treatment for both conditions range from over-the-counter drugs (minimal) to hysterectomy (maximal).
Treatment options in between these extremes vary because of the differences in where the misplaced endometrial tissue is located.
Treatment options must be discussed with the doctor.
Some of the questions to consider are:
- Does the chronic pain affect daily activities negatively?
- Would she want to have children?
- Is the pain intermittent (e.g. just around the menstrual periods)?
- Is the patient near menopause (when adenomyosis related symptoms may go away)?
ADENOMYOSIS TREATMENT
If the symptoms are mild, the doctor may recommend over-the-counter anti-inflammatory drugs just before and during menstrual periods.
For control of more severe symptom, there are other options:
Hormones are used to help control increased estrogen levels that contribute to symptoms.
These include:
- Gonadotropin-releasing hormone agonists
- Oral contraceptive pills
- High-dose progestins
- A levonorgestrel-releasing intrauterine device
- Danazol
- Endometrial ablation is an outpatient procedure. It uses a laser or other ablation techniques to destroy the lining of the uterus. If the adenomyosis being treated is extensive, this may not work well.
- Excisional procedures using laparoscopy cut out the affected adenomyosis areas of the uterus. This has chalked only a limited success because it doesn't get all of the adenomyosis. A method of adenomyomectomy that has had more success involves the reconstruction of the uterus wall with a flap.
- Uterine artery ligation - Uses laparoscopy to cut off the blood supply to the area of adenomyosis. This is reported to have poor success.
- Uterine artery embolization is a minimally invasive procedure with moderately good reported results.
- MRI-guided focused ultrasound surgery (MRgFUS) is a noninvasive procedure which uses focused ultrasound energy delivered to deep tissue without damaging the surrounding tissue.
- Hysterectomy - The complete removal of the uterus, this would eliminate adenomyosis. However it is not appropriate for women who want to have children.
ENDOMETRIOSIS TREATMENT
For mild symptoms, over-the-counter anti-inflammatory drugs may help. For more severe symptoms, there are other options.
Anti-inflammatory drugs may be combined with hormonal treatments.
Hormone supplements may be of help to:
- Regulate menstrual periods
- Reduce endometrial tissue growth
- Relieve pain
These can be prescribed in a staggered fashion, beginning with a low dose of oral contraceptives and seeing how the patient responds.
The first line of treatment is usually low-dose combined oral contraceptive pills. Examples include ethyl estradiol and progestins.
A second-tier of treatment will include progestins, androgens (Danazol), and gonadotropin-releasing hormone agonists (GnRH). These have been proven to reduce endometriosis pain.
The progestins may be taken orally, injected, or as an intrauterine device.
The hormonal contraceptive treatments may stop the monthly periods and relieve symptoms for as long as the person takes them. The periods will return when the patient stops taking them.
I case the patient wants to get pregnant, there's ample evidence that taking and then stopping hormonal treatments may improve the chances of fertility especially with in vitro fertilization.
Conservative surgery can remove endometriosis laparoscopically, while keeping the uterus intact. This may relieve symptoms, however the endometriosis can return.
Laparoscopy can also be used with heat or current or laser treatments to remove the endometriosis.
Hysterectomy (the complete removal of the uterus) and possible removal of the ovaries is considered a last resort.
OUTLOOK
Endometriosis is a chronic condition that has no cure. The medical fraternity is yet to understand what causes it. Nevertheless, this doesn't mean the condition has to impact one's daily life. There are effective treatments such as medications, hormone therapy, and surgery to manage pain and fertility issues. Symptoms of endometriosis usually improve after menopause.
Both adenomyosis and endometriosis can be painful. Both are progressive disorders, but they're treatable and not at all life-threatening.
Early diagnosis and treatment can lead to a better outcome for pain and symptom relief.
Menopause usually relieves adenomyosis symptoms. Some women with endometriosis may still have symptoms after menopause, though this isn't very common.
Both adenomyosis and endometriosis may make it harder to get pregnant. If the patient wants to get pregnant, a talk with her doctor about the best treatment plan would be necessary.
There are new methods of conservative surgery that may be able to relieve pain and symptoms while preserving the uterus and ovaries.
The good news is that there are many ongoing studies on adenomyosis and endometriosis. More about what causes these disorders will be found and new therapies are likely to be developed out of the findings.
