The best way to understand adenomyosis is to imagine your womb as a house with a carpeted room inside. Adenomyosis is a common, non-cancerous condition where the lining tissue (the carpet), called the endometrium, begins to force its way and grow into the walls and foundation — representing the thick muscle layer known as the myometrium.
The underlying system involves this tissue invasion, causing the womb muscle to thicken and swell. This tissue still responds to your normal hormones, causing cyclical issues.
Symptoms severely worsen during the menstrual period because the tissue trapped deep inside the muscle still bleeds every month, but the blood cannot escape. This process creates uterine bleeding, swelling, and irritation (inflammation).
This irritation makes the womb muscle sensitive and spastic, leading to severe and painful cramping and very heavy bleeding.
Experts generally agree that a combination of factors cause adenomyosis.
The leading theory, called the invagination theory, claims the deepest layer of the uterine lining, the endometrium, physically pushes its way into the thick muscle wall because the barrier separating them breaks down.
Several events can cause this barrier damage. For example, physical trauma to the uterus from past surgeries like a C-section (cesarean delivery) or a dilation and curettage (D&C) often creates the openings that allow the lining cells to invade the muscle.
Also, the natural stress of childbirth can injure the uterine tissue, providing a similar entry point. Even without surgery, the uterus sometimes contracts too forcefully and too often, a condition called hyperperistalsis, and this repeated stress causes tiny injuries to the barrier over time, which eventually leads the lining to push through.
Once the misplaced tissue establishes itself in the muscle, hormones and inflammation drive its growth and cause symptoms.
The female reproductive hormone estrogen acts like a fuel that strongly promotes the growth of the abnormal tissue. This explains why adenomyosis only affects women during their reproductive years and usually resolves after menopause, when estrogen levels drop.
Other less common theories, like metaplasia theory, suggest the abnormal tissue develops differently, proposing that cells remaining from when a child developed in the womb or stem cells already present in the uterine muscle might later change into the misplaced lining tissue.
A doctor first suspects adenomyosis when a patient tells them about very bad period pain (doctors call this dysmenorrhea), heavy bleeding, or difficulty getting pregnant. During a physical exam, the doctor often feels the uterus, or womb, is larger or tender.
In the past, doctors needed surgery and lab tests to confirm the diagnosis, but modern imaging now gives doctors a confident answer without an operation. Doctors primarily use two imaging methods, and preferably ultrasound:
This is usually the first test because it’s fast and easy to get. Doctors use special rules, called Morphological Uterus Sonographic Assessment (MUSA) criteria, to look for changes inside the uterus’s muscle wall. MUSA is a set of criteria that experts use to accurately identify and describe the ultrasound features of adenomyosis.
Doctors and sonographers use the MUSA criteria to help ensure they use the same terminology and guidelines when they diagnose the condition. However, they are still revising and refining diagnostic imaging criteria to this day.
They look for direct signs like small cysts (fluid pockets) and bright streaks — showing the abnormal tissue that is physically invading the muscle layer. They also check for indirect signs, such as when one side of the uterine wall looks much thicker than the other.
The MRI often works as the best non-invasive test because it takes very detailed pictures of the uterus. It is used less often, like when diagnoses are unclear, since TVUS is just as sensitive and specific and can be done as an outpatient in the office, while MRI costs considerably more time, money, and effort to schedule and show up later.
The most important thing doctors measure on an MRI is the thickness of the junctional zone (JZ), which is the inner layer of the muscle that separates it from the womb lining. If the JZ measures 12 millimeters or more, it strongly suggests adenomyosis and is generally diagnostic. The MRI also shows small bright spots that are the trapped pieces of menstrual tissue.
Both TVUS and MRI help doctors accurately find the disease, which allows them to start treatment quickly.
Adenomyosis often causes a range of symptoms and physical signs, though medical experts estimate that up to one-third of women with the condition experience no symptoms at all. However, when symptoms do occur, they fall primarily into two groups: abnormal bleeding (changes to the menstrual cycle) and persistent pain.
Patients typically describe severe or intense menstrual cramps that worsen steadily over time.
Women report excessive menstrual blood flow or periods that last significantly longer than usual, a condition doctors call menorrhagia. Abnormal or heavy bleeding in between periods or in irregular intervals is called menometorrhagia.
Some women experience ongoing, non-cyclical pelvic discomfort or a feeling of constant heaviness or fullness in the lower abdomen, which is chronic pelvic pain.
Deep penetration causes pain in some women, likely because the enlarged, tender uterus presses against surrounding structures.
Adenomyosis itself does not always prevent conception, however, it often associates with infertility and an increased risk of miscarriage of around 11-12%. This is due to impaired womb function and embryo implantation.
Doctors also identify specific physical and imaging findings during examination and diagnostic testing that strongly suggest adenomyosis, such as a classic “boggy”, enlarged or tender uterus.
During a pelvic exam, the clinician often notes that the uterus feels enlarged, and tender to the touch.
Imaging tests, particularly TVUS and MRI, consistently show that one wall of the uterus (either the front or back) measures thicker than the other.
The MRI is used to measure the junctional zone. A thickness measuring 12 mm or more strongly indicates the presence of the disease, and is generally considered diagnostic.
Ultrasound pictures often show tiny, fluid-filled bubbles, or cysts, and bright, thin lines that go into the muscle wall, which are pieces of the misplaced womb lining.
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Yes, adenomyosis harms fertility through several mechanical and biological issues that create a poor environment inside the uterus. Adenomyosis is found in 24.4% of infertile women.
The most critical problem involves impaired embryo implantation. This condition alters the womb’s inner lining, changing how it interacts with sperm or an embryo, and studies reveal that women with adenomyosis have noticeably lower implantation rates during IVF cycles.
Furthermore, the misplaced tissue causes the muscle wall to thicken and contract abnormally. These poor contractions can either block sperm movement or cause the uterus to push out a newly implanted embryo.
Adenomyosis also creates a state of chronic inflammation that impairs the womb’s ability to accept an embryo and alters local hormone levels, severely compromising the conditions for a successful pregnancy.
Therefore, modern medicine recognizes adenomyosis as a major cause of infertility, demanding careful diagnosis and specific treatment plans before starting assisted reproduction.
Treatment for adenomyosis primarily manages symptoms (pain and heavy bleeding) and depends heavily on whether a woman wants future children. Removing the uterus (hysterectomy) provides the only permanent cure, but several other options give relief:
Doctors typically start with hormonal therapies, like a hormonal IUD (intrauterine device), aromatase inhibitors, or gonadotropin-releasing hormone (GnRH) medications, which temporarily stop periods to reduce estrogen and shrink the uterus. Non-steroidal anti-inflammatory drugs (NSAIDs) also act as pain relievers, which temporarily eases cramps but come with long-term risks.
For women who want to get pregnant, surgeons perform an adenomyomectomy — cutting out the diseased tissue to preserve the womb.
Uterine artery embolization (UAE) blocks blood flow to the diseased areas of the uterus, causing them to shrink. Doctors sometimes use endometrial ablation — burning the uterine lining to stop heavy bleeding, but this significantly reduces chances of pregnancy.
The most widely supported first-line drug of choice for managing the symptoms of adenomyosis is the levonorgestrel-releasing intrauterine system (LNG-IUS), often known by the brand name Mirena®. This drug effectively reduces both heavy menstrual bleeding and pain by releasing the hormone progestin directly into the uterus, which suppresses the growth of the uterine lining and the adenomyosis lesions.
Other hormonal treatments, such as GnRH agonists or oral progestins like dienogest (Visanne®), also treat symptoms effectively.
No, smoking generally does not cause adenomyosis. In fact, some evidence suggests that smoking may actually lower a woman’s risk for the condition. This happens because smoking reduces the amount of estrogen in the body, and adenomyosis is a disease that needs estrogen to grow.
Interestingly, 2024 research also suggests that cannabis smoking is not associated with adenomyosis risk. However, it also suggests contradictory findings that any past use of tobacco is associated with the condition.
The only treatment option that cures adenomyosis is removing the uterus (hysterectomy), typically reserved for women with severe symptoms who do not plan to conceive.
Other treatment options manage pain and bleeding based on fertility goals. Doctors use hormonal medications, such as a hormonal IUD or GnRH drugs, to lower estrogen and shrink the disease. Each option has its benefits and drawbacks that must be discussed with your provider.
For those who want to get pregnant, surgeons perform an adenomyomectomy (cutting out the diseased parts) to preserve the womb.
Minimally-invasive methods, like uterine artery embolization (UAE), also block blood flow to the lesions, causing them to shrink.
If you have adenomyosis, you should mainly avoid things that raise estrogen levels, body fat, or increase inflammation, as these worsen symptoms. Specifically, limit unopposed estrogen medications and reduce intake of highly processed foods, sugars, and red meats that promote inflammation or weight gain, as body fat holds and increases estrogen exposure.
Stage 4 adenomyosis does not exist as a standard classification. Doctors don’t use a numbered system to describe its severity.
Instead, they classify the condition based on how the tissue spreads: either diffuse (widely spread) or focal (a localized mass called an adenomyoma). Doctors judge the severity by the depth of the tissue invasion to guide treatment.
The ultimate way to stop adenomyosis from spreading is by removing the uterus (hysterectomy), which provides the only permanent cure. However, for women who wish to retain the option of giving birth, doctors suppress the spread using several medical and surgical treatments.
Doctors often use NSAIDS for cramping, plus hormonal treatments like the hormonal IUD or GnRH drugs. For localized areas of growth, surgeons remove the diseased parts through an adenomyomectomy.
Non-surgical treatment options cannot cure adenomyosis; they only manage the symptoms. To manage the disease, doctors use hormonal treatments, like a hormonal IUD or GnRH drugs, which suppress growth by reducing estrogen. They also use non-invasive procedures like uterine artery embolization (UAE), which blocks blood flow to shrink the lesions.
Written by Chiagozie Ekemezie
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