Adenomyosis

Overview

Adenomyosis is a condition that occurs when the endometrial tissue that forms the inner lining of the uterus grows into the uterine muscle layer. This tissue, which should normally be found on the inner surface of the uterus, infiltrates the muscle layer and causes bleeding there during each menstrual period. Over time, this condition leads to thickening and enlargement of the uterine muscle layer and painful menstrual periods.

Adenomyosis is most commonly seen in women between ages 40-50, but can also occur in younger women. For many years also called "intrauterine endometriosis," this condition is especially more common in women who have given birth.

Symptoms vary greatly from person to person. While some women have no symptoms, others may experience severe pain and heavy bleeding. Adenomyosis is a benign condition and does not carry cancer risk. However, symptoms can seriously affect quality of life.

With the onset of menopause, symptoms usually subside on their own. Because when the menstrual cycle ends, bleeding of the endometrial tissue also stops.

Symptoms

Adenomyosis symptoms vary depending on how much the endometrial tissue has spread into the muscle layer and the person's pain threshold. While about one-third of women experience no symptoms, in others symptoms can be quite bothersome.

The most common symptoms are:

• Painful menstrual bleeding. This is the most characteristic symptom of adenomyosis. Much more severe cramping pain is felt during menstrual periods than normal. Pain can begin a few days before the period starts and continue until the period ends. The severity of pain gradually increases over time.
• Heavy and prolonged bleeding. Menstrual bleeding can be much heavier than normal. Clotted bleeding is common. Bleeding duration extends and can exceed seven days. Anemia can develop due to heavy bleeding.
• Chronic pelvic (groin) pain. Constant or intermittent pain may be felt in the pelvic area even outside menstrual periods. This pain can radiate to the back, groin, and legs.
• Pain during intercourse. Pain may be felt during sexual intercourse. This results from the uterus moving and being subjected to pressure during intercourse.
• Uterine enlargement. The uterus feels larger and softer than normal. This can sometimes lead to a feeling of bloating or pressure in the abdomen. During examination, the uterus is noticed to be larger than normal.
• Bloating during menstrual periods. Noticeable bloating may be felt in the abdomen before and during menstruation. This results from edema and blood accumulation in the uterus.

Symptoms are generally more pronounced in women who have given birth and are over 40. Symptoms may intensify as menopause approaches, but completely disappear with menopause.

When to See a Doctor

It is recommended that you see a doctor in the following situations:

• If your menstrual bleeding is increasing and you're bleeding much more than normal, see an obstetrician-gynecologist.
• If your menstrual pain is affecting your daily life, preventing you from going to school or work, evaluation must be done.
• If you constantly experience pain during sexual intercourse and this is negatively affecting your relationship, see a doctor.
• If you have constant pelvic pain even outside menstrual periods, it needs to be investigated.
• If you develop anemia symptoms like weakness, fatigue, dizziness due to heavy bleeding, see a doctor without delay.
• If you're having difficulty getting pregnant and have recurrent miscarriages, adenomyosis evaluation should be done.

Causes and Risk Factors

The exact cause of adenomyosis is not fully understood. However, it is thought that endometrial tissue grows into the muscle as a result of the breakdown of the barrier between the uterine lining and muscle layer.

Some theories thought to lead to this condition are:

• Tissue invasion. As a result of damage to the natural barrier between the uterine lining and muscle layer, endometrial cells infiltrate the muscle layer. This damage can occur especially during childbirth, curettage, or uterine surgery.
• Developmental origin. In some cases, endometrial tissue may have been embedded in the uterine muscle layer during fetal development. This condition begins to show symptoms with puberty.
• Having given birth. Adenomyosis is more common in women who have given birth more than once. Damage to the uterine muscle layer during childbirth is thought to set the stage for this condition.
• Age. It is more common in women between 40-50 years old. The cumulative effect of years of estrogen exposure is thought to play a role.
• Uterine surgery. Risk increases in women who have had previous uterus-related procedures such as fibroid removal, cesarean section, or curettage.

The most important risk factors for adenomyosis are:

• Age. Risk increases significantly over 40.
• Number of births. More common in women who have given birth more than once.
• Previous uterine surgery. History of cesarean section, fibroid removal, or curettage increases risk.
• Presence of endometriosis. Adenomyosis can often be seen together with endometriosis.

Adenomyosis is quite common among women. Studies show that 20-30 percent of women who have undergone hysterectomy (uterus removal) surgery have adenomyosis.

Complications

Adenomyosis does not lead to serious complications in most women. However, problems can develop in some cases.

• Chronic anemia. Prolonged and heavy menstrual bleeding can lead to iron deficiency anemia. Anemia causes symptoms like weakness, fatigue, pale skin, hair loss, and difficulty concentrating.
• Decreased quality of life due to chronic pain. Constant or recurring pain negatively affects work, social life, and family life. Some women are forced to restrict their daily activities due to pain.
• Fertility problems. Adenomyosis can make pregnancy difficult. The inflammatory environment and blood flow disturbances in the uterine muscle layer can prevent the embryo from implanting in the uterus. It can also increase the risk of recurrent miscarriage.
• Sexual dysfunction. Pain felt during sexual intercourse can lead to loss of sexual desire and relationship problems over time.
• Psychological effects. Chronic pain and heavy bleeding can cause anxiety, stress, and depression. Women may live with worry about when symptoms will appear.

Diagnosis

Adenomyosis is diagnosed through history, gynecological examination, and imaging methods. While in the past definitive diagnosis could only be made by examining the uterus after hysterectomy, today diagnosis can be made without surgery thanks to advanced imaging methods.

The diagnostic process typically includes:

• Detailed history and gynecological examination. Your doctor will ask questions about your menstrual bleeding pattern, amount, pain severity, and birth history. During gynecological examination, the size, shape, and tenderness of the uterus are evaluated. In adenomyosis, the uterus usually feels enlarged and soft.
• Ultrasonography. This is the most commonly used method in diagnosis. The uterine muscle layer is examined in detail with vaginal ultrasound. In adenomyosis, thickening, small cystic areas, and irregular appearance are observed in the muscle layer. Ultrasound has a high diagnostic rate when performed by an experienced specialist.
• Magnetic resonance imaging. Used when ultrasound is not sufficient or when diagnosis is uncertain. MRI shows the uterine muscle layer in great detail and is quite successful in determining the extent of adenomyosis. It also helps distinguish adenomyosis from other formations in the uterus (like fibroids).
• Biopsy. Rarely, a small tissue sample may be taken from the muscle layer during hysteroscopy (visualization of the inside of the uterus with a camera). However, this procedure is not always necessary.

Treatment

The goal of adenomyosis treatment is to control symptoms, reduce pain, regulate bleeding, and improve quality of life. The treatment approach is determined according to the person's age, severity of symptoms, desire to have children, and general health condition.

Treatment options include:

• Pain relievers and anti-inflammatory medications. Nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen are used to relieve menstrual pain. These medications reduce the production of prostaglandins that cause pain. They are more effective when started one day before the period begins and used regularly during the first days of menstruation.
• Hormonal treatments. Hormonal medications control symptoms by suppressing the growth of endometrial tissue. Birth control pills regulate menstrual bleeding, reduce bleeding amount, and relieve pain. Progesterone-containing intrauterine device (hormonal IUD) is particularly very effective in reducing heavy bleeding and provides protection for five years. GnRH agonists temporarily stop the ovaries from producing hormones and create artificial menopause. This way the endometrial tissue shrinks and symptoms disappear. However, due to the risk of bone loss with long-term use, they are usually not recommended for more than six months.
• Uterine artery embolization. In this procedure, a thin catheter is advanced through the groin artery to reach the vessels feeding the uterus and small particles are injected. These particles block the vessels, reducing blood flow to the adenomyosis tissue. The tissue deprived of blood flow shrinks and symptoms regress. A few days of hospitalization may be required after the procedure. The success rate is high but careful evaluation should be done in women planning pregnancy.
• Focused ultrasound surgery. In this method performed under MRI guidance, high-intensity ultrasound waves focus on adenomyosis tissue in the uterine muscle layer and destroy this tissue by heating it. It is a non-surgical method and rapid recovery is achieved after the procedure. However, it is an advanced technology method not available in every center.
• Endometrial ablation. This is a procedure where the uterine lining is destroyed by various methods (heat, cold, microwave). It is especially effective in reducing heavy bleeding. However, if adenomyosis has spread to the depths of the muscle layer, it may not be sufficient. Not suitable for women who want to have children.
• Hysterectomy. This is the surgical removal of the uterus completely. It is the definitive treatment for adenomyosis and symptoms completely disappear. However, it is major surgery and is considered as a last resort in women whose desire to have children has ended and whose symptoms cannot be controlled with other treatments. Post-surgery recovery time is four to six weeks.

Living with Adenomyosis

Adenomyosis is a chronic condition and lasts a lifetime. However, there are many things you can do to control symptoms and improve quality of life.

• Learn pain management. To relieve pain during menstrual periods, use a hot water bottle or take a hot bath. Heat relaxes muscles and reduces pain. Start using your pain relievers regularly before your period begins. Herbal teas (chamomile, ginger) can be soothing.
• Pay attention to your nutrition. Stay away from inflammation-increasing foods (processed foods, sugar, excessive caffeine). Omega-3 fatty acids (fish, walnuts, flaxseed) can help reduce inflammation. Fibrous foods (vegetables, fruits, whole grains) help balance estrogen levels. Iron-rich foods (red meat, spinach, legumes) help prevent anemia due to heavy bleeding.
• Exercise regularly. Low-impact exercises like walking, swimming, yoga increase blood circulation, reduce pain, and help manage stress. Especially yoga and pilates strengthen and stretch pelvic muscles. During menstrual periods, choose exercises that don't increase pain.
• Practice stress management. Stress can worsen symptoms. Meditation, deep breathing exercises, relaxation techniques, and hobbies help reduce stress. If necessary, get support from a therapist.
• Track bleeding. Keep a menstrual calendar recording your bleeding amount, duration, and pain severity. This information helps your doctor adjust treatment. If you notice excessive bleeding (needing to change pad every hour, large clots), inform your doctor.
• Pay attention to anemia symptoms. If you notice symptoms like weakness, fatigue, pale skin, shortness of breath, have a blood count done. If iron supplementation is needed, use as recommended by your doctor.
• Talk about your sexual life. If you experience pain during sexual intercourse, communicate openly with your partner. You can reduce pain by trying different positions. If pain continues, don't hesitate to talk to your doctor.
• Share your pregnancy plans. If you're thinking of having children, talk to your doctor. Treatment options should be adjusted according to your pregnancy plan. Some treatments may temporarily prevent pregnancy or be postponed until after pregnancy.
• Get regular checkups. Don't skip your gynecological examinations. If your symptoms change or new symptoms are added, see your doctor without delay.
• Use your medications regularly. If you're receiving hormonal treatment, use your medications as recommended by your doctor. Regular use of medications is critical in symptom control. If you notice any side effects, consult your doctor.
• Get information about alternative treatments. Methods like acupuncture, herbal treatments may provide relief for some women. However, definitely consult your doctor before using these methods.
• Make time for yourself. Living with a chronic illness can be exhausting. Pay attention to rest, your sleep routine, and taking good care of yourself. Listen to your body and slow down when necessary.
• Make arrangements at work. On painful and heavy bleeding days, consider flexible work hours or work-from-home options if available. If necessary, share the situation with human resources at your workplace to request support.

Preparing for Your Appointment

What you can do:

• Keep a calendar of your menstrual periods. Note bleeding days, amount, and pain severity.
• Describe the pain (where, when it starts, how long it lasts, what helps).
• List your previous pregnancies, births, miscarriages, and gynecological surgeries you've had.
• Write down all medications, vitamins, and herbal supplements you're taking.
• Note if there's a family history (mother, sister) of adenomyosis, endometriosis, or uterine cancer.
• Clarify whether you're planning pregnancy.
• Write your questions down in advance.

Questions you can ask your doctor:

• Is the cause of my symptoms adenomyosis or could it be something else?
• What tests do we need to do to confirm the diagnosis?
• How widespread and severe is my adenomyosis?
• I'm planning pregnancy, how will this condition affect my pregnancy?
• Is medication or an interventional method more appropriate for me?
• What are the side effects of hormonal treatments?
• Will I benefit from non-surgical treatment options?
• In what situation should hysterectomy be considered?
• What can I do in daily life to ease my symptoms?
• How often do I need checkups?

Your doctor may ask you:

• How long does your menstrual bleeding last and how heavy is it?
• What days does your menstrual pain start and how long does it last?
• Do you use pain relievers for pain, do they work?
• Do you experience pain during sexual intercourse?
• How many births have you had before and what kind were they?
• Have you had miscarriages before?
• Have you had uterus-related surgery before?
• Does anyone in your family have similar problems?
• Are you thinking about pregnancy?
• What birth control method are you using?