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.

Exploring the Potential of Ultrasound for Endometriosis

Endometriosis is a benign and chronic condition that can cause women to experience pain and fertility problems. For a long time, and to an extent still today, surgery is required to diagnose the disease. However, in the hands of an expert, a transvaginal ultrasound can accurately map deep endometriotic nodules and identify pouch of Douglas obliteration in a noninvasive fashion (Figure 1). Though this statement exhibits optimism in the effort to minimize the use of invasive surgery for diagnostic purposes, there are a few limitations with ultrasound in this scenario.

Leonardi Fig 1

Figure 1: Ultrasound depiction of bowel deep endometriosis and negative sliding sign (can only be noted with dynamic movements) (left) and laparoscopic depiction of bowel deep endometriosis and obliterated pouch of Douglas.

This blog post will attempt to highlight a few key issues with ultrasound’s potential in the realm of endometriosis. We also encourage your comments below on how you feel about ultrasound for endometriosis. Ultimately, we must all be critical of what can and cannot be achieved with ultrasound to ensure appropriate day-to-day clinical practice. This then also allows us to pursue ongoing cutting-edge research endeavors.Leonardi

Our first limitation is in the definition of the word, “expert.”  Thus far, one might attach the term “expert” to those responsible for the bulk of the literature on ultrasound for endometriosis. Certainly, in the view of these academics, ultrasound can see much more endometriosis than previously thought. The belief in the value of ultrasound and expertise in scanning/interpreting scans may trickle down the typical training ladder to fellows, residents, and sonographers. But is there any formal teaching—didactic or tactile? Is there any formal assessment of skill to suggest a minimum level of competency? Is there, at this time, even an understanding of how to evaluate a trainees’ learning curve of endometriosis ultrasound? What is to there to stop an individual from claiming competency when ultrasound for endometriosis is still in its infancy? One concern with pseudo-experts is that they may actually impede the advancement of endometriosis ultrasound integration because surgeons do not verify their findings intraoperatively, leading to skepticism.

Another big problem with the current potential for noninvasive ultrasound diagnosis of endometriosis is the inability to visualize superficial endometriosis, the mildest form of the disease. In surgery, deposits of superficial endometriosis are generally small, only a few millimeters in width and depth, and discolored (Figure 2). They sometimes cause adhesions to form between structures, such as the ovaries and the pelvic sidewall or uterosacral ligament. Thus far, no one has been able to directly identify superficial endometriosis deposits on ultrasound. However, soft markers on ultrasound, such as ovarian immobility and site-specific tenderness (ie, the ability to elicit pain with the pressure of the transvaginal probe during the scan) may hold some secrets to the diagnosis of this enigmatic form of the disease. Until further research supports the routine use of these components in ultrasound for endometriosis, the superficial disease remains a surgical, and therefore invasive, diagnosis.

Condous and Leonardi Fig 2

Figure 2: Laparoscopic depiction of small superficial endometriosis deposit.

Despite these limitations and others not highlighted here, the ability to directly visualize the more severe forms of the disease (ie, ovarian endometriomas, deep endometriosis of the bowel, and pouch of Douglas obliteration) has led to two very clear and significant benefits. One, the patient may be able to receive a diagnosis of disease in a noninvasive fashion, which may guide treatment. Second, if surgery is elected as the treatment of choice, surgeons can prepare. If severe disease is noted on a scan, surgeons can anticipate advanced level surgery, which may necessitate skill from a minimally invasive gynecologic surgeon and/or colorectal surgeon. If no disease is identified on a scan, there will be superficial endometriosis or no disease at all in surgery.

Overall, we are at a much better place right now than we have ever been when it comes to ultrasound for endometriosis. There are still limits that must be addressed, many of which are actively being investigated by dedicated teams around the world. This blog commentary does not attempt to offer solutions to the obstacles highlighted. However, please feel free to comment below if you have any thoughts on an approach to these, or other, limitations.

Have you tried ultrasound for endometriosis? What is your experience with ultrasound and endometriosis? What are your thoughts on the limitations of ultrasound for endometriosis? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community. 

Connect

Mathew Leonardi, MD, FRCSC, is an Honorary Lecturer in the Department of Obstetrics and Gynaecology and PhD student at the Nepean Clinical School, University of Sydney, under the supervision of Associate Professor George Condous. His Twitter handle is @mathewleonardi