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Diagnosis and Treatment of Adenomyosis Question: A friend of mine was talking about a myomectomy for adenomyosis. To me, that's just not logical: If they remove part of the uterus in order to remove the adenomyosis, who's to say they got it all? Also, if the uterus no longer functions to have children, what's the point in keeping it? I mean, it doesn't produce hormones...but with doctors in the past doing hysterectomies left and right, is there a valid reason to keep a diseased organ? Answer: This is a good example of a situation that can have different correct answers, depending upon the patient's circumstances and personal philosophy. To make the correct decision the patient must have a good understanding of her situation, as well as the pros and cons of the various treatment alternatives. With that in mind, let's start with a few definitions. The shape of the uterus is similar to an upside-down pear (in this example, the stem would be coming out of the cervix). Most of the uterus is made up of smooth muscle. Its job is to hold the baby during pregnancy, and to push the baby out during delivery. The inside of the uterus is lined by a thin layer of glands called the endometrium, which is similar to the Teflon lining on cookware. During pregnancy the embryo becomes implanted in the endometrium, which provides the necessary nutrients to the developing fetus until the placenta (afterbirth) develops. In response to estrogen secretion during the first two weeks of the menstrual cycle, the endometrium thickens up. After ovulation, the primary hormone production of the ovaries changes from estrogen to progesterone. Progesterone helps to stabilize the endometrium and ready it for implantation. If pregnancy does not occur, both the estrogen and progesterone production drop, and the endometrium is shed as the woman has her menses. A woman's period is made up of a combination of blood and endometrium. Endometriosis is a condition in which endometrial tissue grows inside the body but outside of the uterus, probably as a result of menstrual fluid flowing back up through the fallopian tubes during a period and dripping inside the pelvis. Adenomyosis is defined as endometriosis within the muscle wall of the uterus. Adenomyosis is usually not a discrete lesion, but often sends out a diffuse network of branching endometrial glands extending from the endometrium and invading the muscle wall of the uterus. These lesions have no real beginning or end. If a cross-section of a uterus with adenomyosis is examined, one will see varying concentrations of endometriosis within the muscle. An area with a high concentration of adenomyosis and little remaining normal muscle tissue is known as an adenomyoma. Adenomyoma is entirely different than a fibroid, which is also known as a leiomyoma. This is a smooth muscle tumor occurring in the wall of the uterus. When removed, fibroids have a look similar to a rubber ball. There is a definite beginning and end to a fibroid. The most common symptoms of patients with adenomyosis are painful periods with a very heavy flow, and potentially anemia (low blood-count) as a result. A normal uterus is fairly hard and firm. A uterus with adenomyosis is usually slightly enlarged, and is soft or squishy to the feel, kind of like a sponge. A careful history and physical exam should raise the possibility of adenomyosis. If the concentration and size of the adenomyosis is large enough, a sonogram (ultrasound) or MRI may be helpful in making the diagnosis. Laparoscopic evaluation may also be helpful in making the diagnosis. When adenomyosis is present, the uterus often looks "sunburned" and blanches like sunburn. However, examination of the surgical specimen (e.g. after a hysterectomy) under a microscope is the only sure method to make an absolute diagnosis of adenomyosis. The treatment options for adenomyosis are similar to those of endometriosis:
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