“Adenomyosis” – with Dr. Michael Silverstein

Dr. Fox: Welcome to the “Healthful Woman” podcast, the fastest-growing podcast in women’s health. Today is Monday, October 17th, 2022. Mike Silverstein joins me today to talk about adenomyosis. Last week, Mike and I spoke about a related condition, endometriosis. As I said in my intro last week, endometriosis and adenomyosis are both gynecologic conditions related to the endometrium or the inner lining of the uterus. And since they sound alike, they often get confused, but they’re different.
My simplest explanation is that in both cases, the endometrium spreads to another location. With endometriosis, it spreads to the pelvis or abdomen, and that causes a lot of pelvic pain or abdominal pain during one’s period, and sometimes it can also cause infertility due to scarring around the fallopian tubes. However, with adenomyosis, the endometrium spreads to the uterine muscle itself causing a lot of uterine cramping and bleeding during the period. If you haven’t heard the podcast from last week about endometriosis, probably makes sense to listen to that one first before today’s. All right. Enjoy today’s podcast. Thanks for listening. Have a great week.
Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Mike, welcome back to the podcast. Great to have you. We discussed endometriosis last time and you were kind enough to come back to talk about, I don’t wanna say it’s sister diagnosis because it’s not really the same thing, but in terms of something that it often gets confused with, adenomyosis. So, if you could help our listeners understand, what is adenomyosis?
Mike: Well, just to remind you about endometriosis, it’s a disorder where the glands and the lining of the uterus have grown outside of the uterus and are implanted on the surface of the uterus, the ovaries, the fallopian tubes, all the other organs that are in there, the bladder, the bowel, the walls of the peritoneal cavity, and menstruate and slough into the peritoneal cavity and cause dire pain. In this particular case, the glands that are coming from the inside of the uterus…now the uterus is a little bit like a fist, about the size of a fist. If you open your hand and look inside, it’s covered with the endometrioma, which are the glands that grow every month and await an implantation, and the absence of an implantation for a pregnancy slough out the cervix.
Since endometriosis is a disorder where the glands are outside of the uterus, adenomyosis is where the glands are in the wall of the uterus. And so this is, depending upon who you read, either less common or more common than endometriosis. Again, it lacks a definitive diagnostic standard, but since the glands are in the muscle of the uterus, if they’re going to proliferate in the first half of the cycle and secrete in the second half of the cycle, when they go to slough off because no implantation has taken place, they slough off into a tight space in the muscle of the uterus and that causes severe debilitating pain with every menstrual cycle.
Unlike endometriosis, where with mid-cycle you’ll often have an alert that something might be going on because a little bit of fluid comes out of the ovary with the egg and lands where endometriosis can be, it does not typically present with mid-cycle discomfort because there’s no peritoneal or abdominal process going on, but these small little glands are pushing out where they’re trapped by muscle. There’s no place for them to release their secretions. So, these patients will present with, similar to endometriosis, severe debilitating menstrual pain that’s gotten worse through their life.
Often is a congenital disorder, meaning you’re most likely born with these glands in the muscle of the uterus. Unaware of any studies that document that they migrate there. And when they slough because no implantation has take place, they cause discomfort. Now, all girls have menstrual discomfort, but these women, as they go through their teens and into their 20s…and there’s also no study that says it presents earlier or later than endometriosis, severe debilitating menstrual pain that starts with being relieved by anti-inflammatories and ultimately requires narcotics and bed rest.
Dr. Fox: Like you said, with the diagnosis for adenomyosis, really the traditional way to diagnose it is after someone had a hysterectomy and a pathologist opens up the uterus and sees these glands in the muscle where they shouldn’t be. And so a lot of the…sort of in the studies, the symptoms that are associated with adenomyosis tend to be the same ones that cause women to get hysterectomies because that’s how they found it. So, things like very heavy bleeding or abnormal bleeding. And they say it happens more in older women because they’re more likely to have hysterectomies, but it definitely can happen in younger women, too, as you said.
Sort of my experience is that I found that it seems to…as opposed endometriosis seems to cause heavier periods, whereas endometriosis does not typically cause heavier periods, adenomyosis might do that. And unlike endometriosis, adenomyosis can be more strongly suggested or potentially even diagnosed on something like ultrasound or MRI because you can see changes in the uterus, an ultrasound or MRI, that you don’t typically see for endometriosis because that’s all the way in the abdomen. So, I’m a little more confident making a diagnosis for someone of adenomyosis on an ultrasound, and I’m almost never confident making one of endometriosis doing an ultrasound for someone.
Mike: Well, just like you mentioned when we had the discussion about endometriosis, sometimes you’ll operate on somebody with chronic pelvic pain and find just a couple of small endometriotic implants. And other times, you’ll operate on somebody for a tubal ligation or something like that and find a peritoneal cavity full of endometriotic implants and a paucity of symptoms. These hysterectomy specimens clearly if they’re done for chronic pelvic pain and you find adenomyosis, it’s a clear aha moment that is valid.
Dr. Fox: Especially if they get better after the hysterectomy.
Mike: Especially if they get better. And I agree 100% that ultrasound is quite useful in supporting your diagnosis. But back to the Silverstein’s five questions, who gets it? How does it present? How is it diagnosed? How is it treated? What’s the prognosis? Who gets it? Again, teens, 20s, worsening pain with menstruation. How does it present? We talked about the chronic pain with menses. How is it diagnosed? I think ultrasound’s a wonderful tool. Since the glands are swelling the size of the uterus, the uterus fills with the glands that line the uterus to fill the muscle that is the uterus. And so if the glands are swelling the size of the uterus, you’re increasing the surface area of the lining of the uterus and you have heavier periods. And so it is supported by that diagnosis that you have heavy exquisitely painful menses.
Dr. Fox: Yeah. Now, ultrasound we usually see the uterus is bigger or bulkier as we call it and frequently asymmetric, meaning the anterior or the sort of more towards, I guess, your belly side of the uterus versus the posterior, typically, it’s quite symmetrical all the way around the thickness of the muscle. But when you see these asymmetric thickening, also there’s various color flows we can look for for increased flow in that area. There’s also something…you know, what’s it called? The junctional zone that we see it’s sort of obliterated because since the glands are sort of going into the muscle you don’t have that smooth demarcation between muscle and gland.
And so there’s a lot of findings on ultrasound, especially someone comes in saying, you know, “My doctor sent me because I’m having heavy periods and painful periods,” and I see this on ultrasound, I’m highly confident it’s adenomyosis at least, right? It could be other things, as you said on top of that, but at least have adenomyosis. But for endometriosis, unless there’s an endometrioma, very rarely can we see anything that is highly correlated with having endometriosis.
Mike: As you mentioned or as we discussed with endometriosis, getting into the diagnostic area, I’m reminded of a medical student who presented a case where they said the patient had pain, came to the emergency room, and CAT scan revealed an enlarged appendix. I’m assuming at some point between the presentation and the CAT scan physician actually spoke to the patient and examined the patient. So, hopefully, prior to your ultrasound, a physician examined this patient.
As I mentioned when we discussed endometriosis, so by manual exam, two fingers gently inserted into the vagina nudging the cervix, the other hand gently on the abdomen receiving the uterus and gently lofting it between the two hands to feel its mobility and its tenderness. Quite diagnostic with endometriosis because the uterus doesn’t budge. There’s a lot of pain. With adenomyosis, you’re initially finding an enlarged uterus, and that uterus is exquisitely tender, and it’s tender 24/7, not just when they’re menstruating because the glands are trapped in the muscle of the uterus.
So, clearly, the patient who presents with this type of chronic worsening menstrual pain, who now has an exam where you can lift the uterus up albeit tender and find it larger than anticipated and tender, certainly supports what we call pretest probability, and going into the ultrasound is often your confirmatory test.
Dr. Fox: And so if you did suspect adenomyosis based on her presentation, based on your exam, based on the ultrasound or MRI, whatever it might be, how would you go about treating it?
Mike: Well, since the root of the pain is menstruation, you avoid menstruation. A very wonderful solution is pregnancy. It should not impact significantly on pregnancy because the lining of the uterus should still be hospitable to kind of implantation. In the absence of plans for a pregnancy, preventing menstruation, most commonly with combination birth control pills.
Unlike with endometriosis where you can use progesterone only, progesterone only works well to slough the lining of the uterus and is not as effective for the glands that are trapped in the muscle. And sometimes if birth control pills don’t work, you have to work a level higher at the pituitary gland where the simbulatory [SP] hormones come out that cause ovulation. But, unfortunately, those medications often are coupled with the side effects if you’re preventing hormonal stimulation to the ovaries in order to eliminate ovulation. You’re also eliminating estrogen production, and that can make the patient quite significantly menopausal, hot flashes, vaginal dryness, mood instability, sleep disorders, not to mention bone loss, and potential cardiac complications.
Dr. Fox: Do you find that something like a long-acting contraceptive like an IUD that releases progesterone to be helpful for adenomyosis?
Mike: Again, as I mentioned about progesterones, they definitely attenuate or thin the lining of the uterus. They may work as well with the glands and the muscle of the uterus, and certainly, it’s a reasonable place to start.
Dr. Fox: Right. And what about something like endometrial ablation, which is, you know, sort of a surgery, sort of a procedure where you go in and either remove or “destroy” the endometrial lining? This is for someone who’s not planning on future pregnancies.
Mike: Well, the truth is I think that is just taking off the surface lining of the muscle of the uterus. You haven’t done anything to oblate the glands that are in the muscle of the uterus. And an outstanding solution for a woman who is not planning a future pregnancy is a simple hysterectomy without removing the ovaries. There’s no alteration in a hormonal function, and since the muscle of the uterus is where the glands are situated, removing the muscle of the uterus can often eliminate their pain.
Dr. Fox: Yeah. And I think this is one of the really big differences between adenomyosis and endometriosis. You know, the overlap is obviously that they both happen during the time of their menstruation, they both can be severely painful, you know, and sort of chronic in that sense, and they’re both going to improve either entirely or mostly when they do hit menopause. Endometriosis might be an exception if they have tremendous scar tissue that then causes pain even without the glands, but usually, they’re much better after menopause.
The main difference is for women who are not yet menopausal but they’re done having children, so however many years that might be 5, 10, 15, 20, whatever it is. A hysterectomy will cure adenomyosis because it’s removing the uterus, removing the muscle that’s causing all that pain. Like you said, the ovaries do not have to come out. She will not become menopausal. She won’t have any change in hormonal function. She just won’t be getting her periods anymore. Won’t have that pain.
But it typically won’t work for endometriosis unless coincidentally, all of her endometriosis was on the surface of the uterus, and that’s it, and nowhere else because the inciting problem for endometriosis is not the uterus, it’s the hormones and the endometrial glands that are all over the place. And so, you know, someone comes in and we’re not sure if they have endometriosis or adenomyosis. It’s almost a relief for them to find out it’s adenomyosis, particularly if let’s say they’re in, you know, their late 30s or early 40s and not planning on more kids, and hysterectomy can remove 10 years of pain for them potentially.
Mike: Absolutely. It’s sort of being stuck between Scylla and Charybdis. For those of you who don’t remember mythology, that’s a rock and a hard place. On the one side of the ship was the whirlpool, on the other side was the rock, and you had to get right down the middle or get sucked into the whirlpool or hit the rock. Neither is a pleasant diagnosis to have. Both have their advantages, both have their disadvantages.
In my mind, there is a cure for adenomyosis, and there is not an effective cure for endometriosis. And so the lesser of the two evils, even though both are quite evil, is most likely adenomyosis because there absolutely positively is a cure.
Dr. Fox: Yeah. But as we said, unfortunately, it’s only gonna work if you’re done having kids. And there’s also some overlap with adenomyosis and fibroids in terms of sometimes you can have fibroids and then have something that looks like it might be fibroid but it might be sort of a spherical region of adenomyosis, like a focal area. We call that an adenomyoma, which isn’t really true, but we call…you know. It’s not really a fibroid, it’s adenomyosis. And sometimes people will get surgery to resect just that specific area. Whether that helps or not is unclear.
You know, and also with pregnancy, occasionally, if the adenomyosis is really extreme and it gets really close to the lining, it could have an impact on pregnancy, but we don’t really know enough about that to know for sure. But I do agree that neither is a pleasant diagnosis to have, but if you had to choose one, probably adenomyosis because there is a light at the end of the tunnel that’s earlier, I would say, than endometriosis, which is a good thing probably.
Mike: And for women who are not done with their childbearing, clearly, pregnancies should give them a relative several month alleviation of their symptoms. Sometimes the more pregnancies, the better for them, and for us.
Dr. Fox: Yeah. Good for business. Wonderful. Well, Mike, thank you for coming again to talk about adenomyosis, and for last week talking about endometriosis. Again, both relatively common, lot of overlap between the two in terms of symptoms and the fact that they’re related to the endometrial glands, so they both present at the time of periods. But as we discussed last week and this week, they’re very different, different causes and frequently different treatments. So, thanks for helping to clear those up.
And obviously, for our listeners, if you’re concerned that you may have one of these conditions, really the place to turn, other than Google, of course, is your gynecologist who can probably make the diagnosis or help make the diagnosis for you and then start treatment for you. So, thanks a lot, Mike.
Mike: Thank you, Dr. Fox. Keep it on.
Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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