Adenomyosis: Causes, Diagnosis and Therapy as well as Differentiation from Endometriosis

Diagnosis: How can adenomyosis be diagnosed?

Strictly speaking, the diagnosis of adenomyosis can only be clearly established by histology, i.e. the examination of a tissue sample [9]. However, other non-invasive methods are now also used for diagnosis.

Non-invasive diagnostic procedures

• Sonography
  When diagnosing by means of sonography, a distinction is made between conventional 2D ultrasound and the newer elastrography ultrasound, which is also called 3D ultrasound. Both ultrasound procedures are performed using a vaginal probe. In clinical practice, 2D ultrasound is usually used. Both methods are used to determine the thickness of certain areas as well as their structure. 3D ultrasound can additionally be used to determine the elasticity of tissue. Therefore, a combination of 2D and 3D ultrasound allows a better assessment of whether changes in the uterine muscles are adenomyosis [13]. According to the guideline program for the diagnosis and treatment of endometriosis (and adenomyosis), the suspected diagnosis of “adenomyosis” should first be clarified by ultrasound.

• Magnetic resonance imaging
  Magnetic resonance imaging is also an imaging procedure. It has comparable results to sonography in terms of thickness and structure of the junctional zone. However, the results are more reproducible. According to the guideline program, magnetic resonance imaging is considered a second-line diagnostic procedure. However, if it is performed by an experienced radiologist, it is very well suited for the differentiation of fibroids as well as prior to surgical interventions in fertility patients (fertility patients).

Invasive procedures for diagnostics

• Hysteroscopy
  Hysteroscopy is a mirror examination of the uterus. An endoscope is inserted into the uterus through the vagina, through which the inside of the uterus can be viewed. Adenomyosis cannot be directly visualized during this examination, as only the very top layer of the uterine lining is viewed. However, clues, such as severely dilated vessels, can be seen that indicate adenomyosis. In addition, tissue samples can be taken during a hysteroscopy for later examination. However, these tissue samples provide only limited conclusive results, as they are usually obtained too superficially.

• Laparoscopy
  During laparoscopy, the endoscope is inserted into the abdomen through a small incision. Working instruments can be introduced into the abdominal cavity through a second small incision. In this way, tissue samples can be taken in a targeted manner. By means of laparoscopy, the position and size of the uterus can be easily estimated, which gives conclusions about the existence of adenomyosis, since the uterus may be enlarged in this case. However, adenomyosis is often difficult to localize externally during laparoscopy, making sampling difficult and almost never performed outside of therapeutic surgery.

  According to the guideline program, biopsies should not be used as part of the diagnosis of adenomyosis.

Therapy: How is adenomyosis treated?

Since the causes of the disease are not yet clear, it is not yet possible to treat and cure adenomyosis causally. However, there are several therapeutic approaches, both drug and non-drug. Which form of therapy is used depends on the specific individual case. In particular, the patient’s age and whether she wishes to have children are taken into account.

Drug therapy approaches for adenomyosis

Due to the proximity of adenomyosis to endometriosis, drug treatment concepts are often based on experience in the therapy of endometriosis. All drug treatments that can be used so far show their effect only as long as the treatment itself lasts. A significant proportion of women (the proportion varies greatly depending on the study) do not respond at all to the drug treatment approaches or continue to struggle with residual symptoms.

The main drug therapy concepts are:

• Hormonal treatment approaches
  Different substances can be used as part of hormonal therapy. In addition to progestins, these include GnRH analogs, aromatase inhibitors, and levonorgestrel IUDs. Hormonal therapeutics can be administered in a variety of ways: The agents can be applied locally, such as by hormonal coil. Alternatively, they can be administered by injection into the subfatty tissue (subcutaneous) or into the muscle tissue (intramuscular).
• Non-hormonal therapy approaches
  Furthermore, based on experience in the treatment of endometriosis, non-steroidal anti-inflammatory drugs (= painkillers) are used, since pain is the main symptom in adenomyosis.
• Integrative medicinal therapy approaches
  According to the guideline program, treatment approaches from traditional Chinese medicine, especially the use of San Jie Zhen Tong capsules in particular, have not yet been found to have any clear positive effects.

Surgical treatment options for adenomyosis

The main surgical treatment options are:

• Hysterectomy
  Hysterectomy is a hysterectomy or the removal of parts of the uterus. Despite the fact that in adenomyosis the ingrowths are found exclusively in the uterus, the pain associated with the condition cannot always be completely eliminated. Hysterectomy can lead to other complications and is not suitable for women who wish to have children.
• Resection
  Here, the parts of the uterus affected by adenomyosis are removed in one operation. The uterus as a whole organ remains intact. After the operation, individual recommendations usually apply to births, e.g. the performance of a planned caesarean section.
• Embolization
  During embolization or endometrial ablation, the growths are removed or cut off from the supply of nutrients through the blood vessels. These procedures are only suitable for women who have completed their pregnancy or do not wish to have children. According to the guideline program, these procedures should only be used in the context of studies.

Because of the prolonged occurrence of pain, women with adenomyosis should consider multimodal pain management to additionally improve their quality of life.