Menstrual Pain: Is it Adenomyosis?

Frequently, during daily ultrasound consultations, female patients complain about certain symptoms during their menstrual period, whereas other women go through their monthly cycle without experiencing pain and might feel just a little discomfort associated with their period.Ticci

For those women who do suffer from various common menstrual disorders that can cause stress, pelvic ultrasound is commonly used to investigate any underlying medical problems in menstrual abnormalities.

For example, before speaking with her physician, Brianna didn’t know which symptoms were normal and which were not, since she always thought that a cycle that’s “regular” for her may be abnormal for someone else. She was just chilling at a regular doctor’s checkup when the physician advised her about a vaginal ultrasound after she told him about her symptoms during her menstrual period.

Brianna had never experienced a transvaginal ultrasound before and she thought that it was a little weird and awkward, although some of her friends had told her a while back that the procedure was not painful.

Brianna was referred to my office for the ultrasound exam. She complained about a persistent pelvic pain during her period and about heavy bleeding.

Ultrasound findings:

  • enlarged globular uterus with different densities within the myometrium
  • pockets of fluid within the muscle of the uterus (myometrial cysts)
  • linear acoustic shadowing without the presence of fibroids and echogenic linear striations, like stripes

That’s adenomyosis and it’s very common. And she’s probably never heard of it.

 

 

 

Adenomyosis

Adenomyosis is a common benign gynecologic disorder and its etiology and association with infertility are still unclear. It is a benign disorder previously associated with multiparity but recently, an association with infertility has emerged.

Adenomyosis can be asymptomatic or present with menorrhagia, dysmenorrhea, and metrorrhagia.

Other symptoms may be painful intercourse and/or persistent bladder pressure. These symptoms usually occur in patients aged 35 to 50, and the condition may affect 65% of women.

The patient looked at me while I tried to quell her fears, trying to explain that it is just an unusual thickening of the uterine wall, caused by glandular tissue being pushed into the muscle.

“It’s cancer?” That’s the first question.

“No, it’s not cancer.” I try to explain: it’s something I saw on the ultrasound called adenomyosis and it’s not going to turn into cancer.

The patient probably had never heard that word before and she’s asking how to spell it so she could go home and Google it.

“Is that a bad thing?” That’s the next question.

I answer, “no, it just doesn’t sound like a good thing. ”

 

Adenomyosis and Endometriosis

Brianna is actually very worried at this point. She’s heard the word “Endometriosis” before because some of her female friends have had it and they thought that, perhaps, that was the cause of their fertility problem.

That’s the next question.

“Is adenomyiosis similar to endometriosis?”

I try to explain that endometriosis happens when endometrial cells are outside the uterus. Adenomyosis is when these cells grow into the uterine wall.

This is my answer and I’m trying to reassure my patient that the two syndromes are quite different. Endometriosis is much more severe. Because Brianna remembers that her friends had pregnancy problems, she’s now scared to death.

Pregnancy and fertility, that’s the great issue.

 

Pregnancy and fertility

“Is it possible to get pregnant with Adenomyosis?”

“Don’t be too concerned, Madam” is my answer.

Evidence that links adenomyosis to fertility is limited to case reports and small case series. But there is a significant association between pelvic endometriosis and adenomyosis (54% to 90% of cases), and it is well known that endometriosis causes infertility. For this reason, findings of infertility were due to endometriosis rather than adenomyosis.

At this point in the conversation, I really think that it is very important to calm the patient.

“In most women, it’s not going to have a medical impact. Sometimes, doctors don’t even tell their findings because it’s not really clinically significant,” I say to her.

 

Treatment

Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, including a high risk of miscarriage and obstetric complications.

The therapeutic choice depends on the woman’s age, reproductive status, and clinical symptoms. However, so far, few clinical studies focusing on medical or surgical treatment for adenomyosis have been performed, and no drugs labeled for adenomyosis are currently available. Nonetheless, the disease is increasingly diagnosed in young women with reproductive desire, and conservative treatments should be preferred.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. An antiproliferative effect of progestins suggests their use for treating adenomyosis by reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to induce regression of adenomyosis by relieving pain and reducing bleeding.

There is evidence on several surgical approaches for the improvement of adenomyosis-related symptoms; however, there is no robust evidence that they are effective for infertility.

 

 Let’s go back to our office

After this long talk, Brianna realized she didn’t need to freak out.

One thing she really couldn’t understand is why she’d never heard the name of this condition.

She was also kind of upset because she spent her teenage years suffering so much from pelvic pain during periods and now that she’s ready to have a family and give birth, a doctor tells her about an annoying medical condition, gives her all this news that explains all her symptoms, which may cause fertility problems and she’d never heard of it before!

Any suggestions for getting the word out about adenomyosis?

 

Do you have any suggestions for getting the word out about adenomyosis? Do you have your own experience to share? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Pietro Ticci, MD, is originally from Florence, Italy, and has been a medical doctor in the Florence Area (Tuscany) since 1995. Currently, he is an Ultrasound Physician at his private medical facilities in the Florence Area.

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