Eva is 37
years of age has 2 children; 6 and 4. For many months she had been having very
heavy and painful periods. She was unable to cope with her day to day life; her
quality of life was getting progressively worse. She went to see her GP, and
complained to him about all her problems. He asked her if she had any difficulty
with her bowel and urination, she immediately answered yes. I have pain both on
urinating and bowel action and also frequency of passing urination. When the GP
examined her he noticed that she was looking pale, he could feel her enlarged
uterus on abdominal examination and confirmed this on pelvic examination, that
it was about the size of 12 -14 weeks of pregnancy it was hard and tender. The
uterine size is expressed with reference to the size of pregnancy; however
during pregnancy it is soft. He did her haemoglobin, this was low 9.6gm (Normally
it is about 11-12). He was an experienced GP, and gave her a diagnosis of a
uterine Fibroid or a condition called Adenomyosis.
Adenomyosis
is a condition in which the endometrial cells grow within the uterine muscle
layers. It can be scattered in the muscle or form a mass like effect, unlike
fibroids it does not have a capsule or an outer cover. It is believed that it
affects up to 65% of females in their life time. A few decades ago it was
thought that it does not affect young women who have had no children. Recently
with the improvement in diagnosing Adenomyosis (ADENO) with Ultrasound and MRI
it is believed that 35% of women suffering from ADENO are nulliparae’s (women
who have never had a pregnancy), in fact in English medical literature some
cases had been reported in adolescent girls. One third of the females suffering
from ADENO have no symptoms. Others suffer from heavy painful menstrual
periods, lower abdominal pain, and pain on intercourse, passing urine and on
bowel actions. It also causes infertility, miscarriages and even premature birth.
If associated with polycystic ovarian syndrome it is even worse due to high
oestrogen levels. This makes IVF difficult due to altered uterine shape, uterine
peristalsis, and makes embryo implantation difficult; a toxic and altered
hormonal environment makes it further worse.
One problem
is that it is a long disease, which lasts for years almost up to menopause. It
often becomes mild after menopause or goes away. I have removed some very
enlarged painful uteri, in post menopausal women. A patient’s
medical history and a clinical pelvic examination give a good clue to its
diagnosis. Blood tests can be done to assess a woman’s condition. New high
resolution ultrasound and MRI give a precise diagnosis. MRI is an expensive test
and not always available ultrasound is nearly as good. In recent times it has
been advised to always keep AENO in mind if you have a young adolescent girl
with intractable pain and painful period, please do an ultrasound.
Why does
ADENO happen? It can be due to trauma to the myometrial and endometrial zone
during child birth, an operation such as curettage, caesarean, this is a process
of tissue injury repair. The endometrium invades into the myometrium. The other theory is that, stem or embryonic
cells change into endometrial cells and make these endometrial nests or even
masses.
The
treatment of ADENO initially conservative especially if the woman is young and
fertility is an issue. Antinflamatory tablets
are given during periods so that they help pain and excessive bleeding, its
effect are minimal to moderate. Next in the line of treatment are hormones, they
are either given to make the periods milder or stop them completely. They all have their side effects and most of
them stop fertility, however the good thing is that all of them are temporary. Let’s start from oral contraceptive pills,
then progesterone tablets or injections and vaginal rings. These also give
Adenomyosis time to heal, but how much it does; we do not know. When they are stopped the problem starts
again. Another treatment is a progesterone implant a small rod implanted in
your upper arm under the skin it lives there for 3 years. It can cause some
irregular spotting, prevents pregnancy.
One of the good hormone is Danazol tablets, or danazol loaded
intrauterine device which fitted in your uterus for 6 months. This has a great advantage that a woman can
still achieve a pregnancy while she is using this. A strong hormone treatment is Gonnadotrophin
releasing Hormone (GnRH). This is given as an injection every at 1 to 3 monthly
intervals. This suppresses our pituitary gland, thus our ovaries, hence no more
periods. This cannot be a very long term treatment; it causes side effects like
menopause. Add on treatments are given for these. One serious side effect is the loss of bone
density. In contrast to this, a group of drugs called Aromatase inhibitors which
stop the formation of oestrogens in the body from other hormones that exist in
the body fat. They are also found to be useful particularly in obese women
where extra oestrogen is formed in the body fat. GnRH is unable to do this.
An present
an intrauterine device containing Levonorgestal is found to be the best
reversible treatment of Adeno. It prevents fertility and can be used repeatedly,
after every 3-5 years. The failure rate
of treating symptoms is only 20 percent. There is a smaller IUD now available
and can be tried in adolescents. Local excision of adenomyosis has been tried,
but it is not easy and long term results are a bit questionable and unsatisfactory.
The treatment of ADENO depends on, if fertility is to be preserved. Hysterectomy
is the best treatment, although uterine artery embolization and endometrial
ablation is also tried with some success. As long as a patient agrees to surgery, a hysterectomy
can be performed abdominally, vaginally or laparascopically and now even robotically.
Generally ovaries
do not need to be removed. In some very
difficult cases it is found to spread into the bladder and bowel.
Adenomyosis
is a difficult and painful condition from which women used to suffer a lot in
the past, but the new techniques of diagnosis and treatment have helped the gynaecologist
in its management.
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