Adenomyosis: Severe Menstrual Pain and Complicated Pregnancy

Dysmenorrhea is a discomfort familiar to many women. Ordinary cases can often be managed with painkillers or a warm drink. However, the pain is so severe for some individuals that standard remedies barely make a dent. This level of intense dysmenorrhea demands caution, as it could indicate an underlying physical condition.

Mary, a young woman, has grappled with excruciating dysmenorrhea. Her monthly periods have become a haunting ordeal, with even her attempts to lead a healthy lifestyle failing to alleviate her deep-seated agony.

Over time, Mary's fear and depression deepened. She relied heavily on painkillers, seeking relief from doctors across various medical facilities and pursuing a comprehensive solution to her debilitating dysmenorrhea.

Upon a thorough examination, it was revealed that her dysmenorrhea was not a run-of-the-mill issue but a consequence of a condition known as adenomyosis.

Upon reviewing her condition, many doctors shook their heads, revealing that severe adenomyosis was the root cause of her dysmenorrhea, and it also had the potential to complicate her pregnancy . This revelation hit Mary like a bolt from the blue, explaining her prolonged struggle to conceive.

What is Adenomyosis ?

Adenomyosis is a benign uterine disorder characterized by endometrial glands and stroma in the myometrium, accompanied by the reactive growth of smooth muscle cells around the myometrium.

Like endometriosis, adenomyosis occurs due to endometrial tissue migrating to unintended locations and embedding itself in abnormal uterine areas. This condition typically arises in women of childbearing age, with an incidence rate ranging from 7% to 23%. Clinical manifestations of adenomyosis encompass severe dysmenorrhea, heavy menstrual bleeding (sometimes leading to severe anemia), and infertility, all of which significantly impact physical and mental well-being.

Research indicates a correlation between adenomyosis and infertility, where the condition might hinder normal embryo implantation and contribute to abnormal early and late miscarriages.

The factors contributing to adenomyosis-related infertility are multifaceted. One significant aspect is the enlargement of the uterus. Since the endometrial basement layer lacks submucosa, the endometrium directly contacts the muscle layer. Moreover, many adenomyosis patients often experience comorbid conditions like uterine fibroids and endometrial hyperplasia, which negatively influence fertilized egg viability and increase the risk of miscarriage and embryo termination, thus impacting fertility.

Additionally, in women with adenomyosis, uterine contractions in frequency, timing, and amplitude can be altered. Even if successful fertilization occurs, impaired uterine implantation can follow due to the uterus' suboptimal environment, potentially affecting the subsequent development of the fertilized egg.

However, it's essential to note that not all cases of adenomyosis result in infertility, although the likelihood of infertility does increase. Thus, patients should seek treatment, particularly when experiencing discomforting symptoms.

Treatment Options for Adenomyosis

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the primary choice for alleviating adenomyosis pain and reducing menstrual flow. Side effects, such as gastrointestinal reactions and occasional abnormal liver and kidney function, should be monitored during long-term usage.

Oral contraceptives mitigate pain associated with adenomyosis and decrease menstrual bleeding. Some potential side effects include digestive tract symptoms or abnormal liver function, particularly among patients over 40 or those with high-risk factors.

Oral progesterone medications, including synthetic progesterone dienogest, alleviate pain and reduce menstrual flow. Dienogest moderately suppresses gonadotropin secretion through negative feedback, resulting in a low estrogen endocrine environment. This inhibits endometrial hyperplasia, inflammation, and angiogenesis. Irregular uterine bleeding is the primary side effect.

Gonadotropin-releasing hormone agonists (GnRHa) effectively and swiftly relieve pain, address menorrhagia, and decrease uterine volume. However, discontinuation of GnRHa may lead to uterine enlargement post-menstrual recovery, accompanied by the return of symptoms such as dysmenorrhea.

The levonorgestrel intrauterine sustained-release system (LNG-IUS) offers a convenient option, continuously releasing levonorgestrel over five years. Clinical evidence demonstrates that LNG-IUS effectively treats adenomyosis-associated dysmenorrhea, chronic pelvic pain, and menorrhagia.

Fuyan Pill , a traditional Chinese medicine, is another viable treatment that offers relief from pain and effective menstrual regulation. Comprising over 50 natural plant ingredients, its long-term usage poses no harm to the body.

Total hysterectomy, involving the removal of the uterus, represents a radical treatment option for symptomatic adenomyosis patients. This procedure can be performed laparoscopically, via laparotomy, or vaginally, with the choice of surgical approach influenced by factors such as uterine size and pelvic adhesion.

Fertility-preserving surgeries are viable alternatives for patients aiming to retain their fertility. Medication to alleviate symptoms and promote fertility is often the first step, followed by preserving the uterus through surgery when long-term drug treatment is intolerable or unsuccessful. The timing of fertility-preserving surgery is determined by carefully considering ovarian function and adenomyosis type.

Alternative treatments such as uterine artery embolization, high-intensity focused ultrasound, and ablation may be considered for patients not seeking fertility preservation.