Adenomyosis: Diagnosis and Management

 

Am Fam Physician. 2022 Jan ;105(1):33-38.

  Patient information: See related handout on adenomyosis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the rest may present with heavy menstrual bleeding, pelvic pain, or infertility. Heavy menstrual bleeding is the most common symptom. Adenomyosis is distinct from endometriosis (the presence of endometrial glands outside of the uterus), but the two conditions often occur simultaneously. Risk factors for developing adenomyosis include increasing age, parity, and history of uterine procedures. Most patients are diagnosed from 40 to 50 years of age, but younger patients with infertility are increasingly being diagnosed with adenomyosis as imaging modalities improve. Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging. Treatment of adenomyosis typically starts with hormonal menstrual suppression. Levonorgestrel-releasing intrauterine systems have shown some effectiveness. Patients with adenomyosis may ultimately have a hysterectomy if symptoms are not controlled with medical therapy.

Adenomyosis is a benign uterine disorder in which endometrial glands are found in the myometrium of the uterus. Adenomyosis is distinct from endometriosis, which is the presence of endometrial glands outside of the uterus. Adenomyosis is a poorly understood condition.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Use transvaginal ultrasonography or pelvic magnetic resonance imaging to noninvasively diagnose adenomyosis.6,9

C

Diagnostic accuracy studies

Patients with adenomyosis not desiring pregnancy can use a levonorgestrel-releasing intrauterine system (Mirena) to help reduce heavy menstrual bleeding and pain.6

B

Results from a limited cohort study showing decreased blood loss and pain

Hysterectomy is definitive treatment of adenomyosis for women who are past childbearing age if other therapies are not effective.6

C

Consensus opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Use transvaginal ultrasonography or pelvic magnetic resonance imaging to noninvasively diagnose adenomyosis.6,9

C

Diagnostic accuracy studies

Patients with adenomyosis not desiring pregnancy can use a levonorgestrel-releasing intrauterine system (Mirena) to help reduce heavy menstrual bleeding and pain.6

B

Results from a limited cohort study showing decreased blood loss and pain

Hysterectomy is definitive treatment of adenomyosis for women who are past childbearing age if other therapies are not effective.6

C

Consensus opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Two theories prevail regarding the pathogenesis of adenomyosis.1,2 The first theory suggests that with injury of the endometrium, the basalis endometrium invaginates into the myometrium through an altered or interrupted junctional zone creating adenomyotic lesions. The tissue injury and repair theory may help explain why having a previous uterine procedure (e.g., cesarean delivery, dilation and curettage) increases the risk of subsequent adenomyosis. The second theory suggests that adenomyotic lesions arise from metaplasia of embryonic pluripotent Müllerian remnants. Adenomyosis can be classified as diffuse (involving a large area of endometrium) or focal.1

Epidemiology

The diagnosis of adenomyosis was previously confirmed in only post-hysterectomy cases, and it was thought to predominate in patients older than 40 years. Improved imaging makes it clear that younger patients also have adenomyosis.1 In one study of 985 symptomatic patients seen in a gynecology clinic using specific ultrasound diagnostic criteria, adenomyosis had a 20.9% prevalence in the study population (including pre- and postmenopausal, nulligravid, and multiparous patients), with a range of 10% to 35% in histology reports after hysterectomy.3

A population-based study of 650,000 patients estimated the overall incidence of adenomyosis at 1%, or 29 per 10,000 person-years, over a 10-year period based on International Classification of Diseases, 10th ed. (ICD-10) coding.4 Of those with adenomyosis, 90.8% had associated clinical

The Authors

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SARINA SCHRAGER, MD, MS, is a professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health, Madison....

LASHIKA YOGENDRAN, MD, MS, is an assistant professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health.

CRYSTAL M. MARQUEZ, MD, is an assistant clinical professor in the Department of Family and Community Medicine at State University of New York—Downstate, Brooklyn.

ELIZABETH A. SADOWSKI, MD, is the director of Gynecologic Imaging and a professor in the Departments of Radiology and Obstetrics and Gynecology at the University of Wisconsin School of Medicine and Public Health.

Address correspondence to Sarina Schrager, MD, MS, University of Wisconsin, 1100 Delaplaine Ct., Madison, WI 53715 (email: sbschrag@wisc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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20. Dessouky R, Gamil SA, Nada MG, et al. Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy. Insights Imaging. 2019;10(1):48.

21. Krentel H, Cezar C, Becker S, et al. From clinical symptoms to MR imaging: diagnostic steps in adenomyosis. Biomed Res Int. 2017;2017:1514029.

22. Chapron C, Vannuccini S, Santulli P, et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update. 2020;26(3):392–411.

 

 

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