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Today we would like to introduce you to Dr. Alicia Vázquez Sarandeses, one of the latest specialists to join the Tambre team in order to make the dream of all the patients who come to see us a reality. Dr. Vázquez has chosen an interesting first topic to address: adenomyosis, a condition which is sometimes confused with other diseases such as fibroids and which we often see in our clinic. Would you like to find out what our new specialist has to say on the subject? Keep reading!
What is adenomyosis?
Adenomyosis is a disease characterized by the presence of endometrial glands in the muscle wall of the womb, the myometrium. Within the uterus there is the endometrium which forms the inner layer (which thickens and sheds when menstruation occurs) and an outer muscle layer that is the myometrium which forms the walls of the uterus. In short, adenomyosis involves the presence of endometrial tissue in the myometrium.
Why does adenomyosis occur?
We don’t know for certain. The boundary between endometrium and myometrium has been called the ‘endometrial−myometrial interface’ and it originates from the uterine contractions that occur during the menstrual cycle. Different studies have observed alterations in the pattern of these contractions in women with adenomyosis. Therefore, disregulation of the contraction mechanism is considered to be the cause of this pathology. Either by alteration (dysperistalsis) or by excess contractions (hyperperistalsis). This mechanism based on the contractional alteration of the uterus is also observed in some women with endometriosis.
Is adenomyosis related to endometriosis or other pathologies?
Adenomyosis can be found in women who also have uterine fibroids or who suffer from endometriosis. In these cases, the coexistence of fibroids or endometriosis with adenomyosis makes women who have it present more frequently with severe pelvic pain.
It is important to note that in situations in which in endometriosis is present with adenomyosis the need for assisted reproduction may be greater.
How is it diagnosed?
Diagnosis is done through imaging tests such as:
- Gynecological ultrasound.
- MAGNETIC resonance imaging.
- Hysteroscopy which allows direct visualization of the uterine cavity and an evaluation of the existence of adenomyosis.
In addition to imaging tests, the symptoms that women share with us alert us to the possibility they may be experiencing the condition.
What symptoms characterize adenomyosis?
About 30% of women with adenomyosis are asymptomatic so if found it is usually when performing a gynecological ultrasound at a checkup or at the time of starting treatment. However, most will have symptoms and these are the main ones:
- Pelvic pain: Pelvic pain associated with adenomyosis can present as one of these forms or as the coexistence of all of Accordingly, we may notice severe pain whilst mensturating (dysmenorrhea), pain with sexual intercourse (dyspareunia), or chronic pelvic pain.
- Abnormal bleeding: Although this symptom is more common in nulyparous women, it can also occur in any woman affected by Some of the factors that cause this bleeding are thought to be due to a larger uterine size (common in adenomyosis), increased blood vessels in this area, alteration of uterine contractions, or increased hormone production.
- Fertility affectation: Many studies have found adenomyosis in a high percentage of women who presented with reproductive problems. Adenomyosis is known to affect a woman’s fertility and also the development of gestation.
Are there multiple grades, types, or levels?
At present there is no classification for adenomyosis. Different expert groups have proposed various classifications, but we currently do not have any that are definitive.
Similarly, a consensus has also not been reached which describes and defines possible degrees of adenomyosis – in reality, we can encounter a wide variety of effects: from a slight thickening of the interface zone (contact area between the endometrium and the myometrium) to extensive lesions that invade much of the myometrium. Depending on the extent of adenomyotic lesions, a classification by levels I (slight invasion) to IV (higher level of invasion) is used. However, as I have mentioned, none of these classifications have been adopted or validated by the different reference scientific societies.
We will find multiple factors when analyzing adenomyosis: extension, invasion, location, appearance of injuries… All of them must be carefully evaluated in order to obtain the most accurate diagnosis and ascertain the possible consequences.
What possible treatments or surgeries can be performed to alleviate adenomyosis?
We must be clear that although adenomyosis produces multiple symptoms that can affect our quality of life and reproductive capacity, it is a benign condition.
There is still much debate about this condition so we do not have a single valid treatment therefore there are several therapeutic possibilities. Fundamentally we can offer:
- Medical treatment: anti-inflammatory drugs and hormone treatments (hormone IUD, progesterone pills, combined contraceptives, gondotropin-releasing hormone analogues (a-GNRH).
- Surgical treatment: reserved for very specific individual cases. Generally not for women who wish to conceive. Some options may include wedge myometrial resection or adenoidectomy.
In general, for women who wish to conceive we will use gondotropin-releasing hormone (a-GNRH) analogues that have been proved to be beneficial in such cases. They may be administered prior to the initiation of assisted reproduction treatment, or after obtaining oocytes and before embryo transfer. Each case must be evaluated individually.
How does a diagnosis of adenomyosis affect fertility?
Some studies have shown that altered regulation of contractions can affect sperm transport through the Fallopian Tube. Adenomyosis can have a negative impact on embryonic implantation and fertility. It has been associated with less probability of gestation and with higher rate of gestational loss. Many studies have found adenomyosis in a high percentage of women who present with reproductive problems.
If we suspect adenomyosis it is essential to carry out a thorough evaluation before diagnosis.
Uterine normality is important for proper reproductive development. In the event of fertility problems, uterine integrity and viability is critical to the success of assisted reproduction techniques. Therefore, a uterine evaluation should not be restricted only to the uterine cavity and an overall assessment of the uterus should be performed: cavity-endometrium and myometrial walls and the relationship between the two.
What treatment would be offered to women with adenomyosis when they visit Clínica Tambre?
In the clinic we will carry out a uterine and health evaluation with the aim of obtaining a detailed diagnosis which will offer the best and most appropriate reproductive technique likely to result in a positive result. In the case of women seeking gestation there are a number of treatment and therapeutic possibilities and therefore an accurate diagnosis is the key to choosing the most appropriate treatment for each individual.