08 Nov Indications for Surgery: Adenomyosis
As a patient, it is very difficult to understand when surgery is needed – or not. Often patients go online to find out information about their condition, and all too often they become confused and even misled as to whether or not surgery is something they need. Here we discuss the top three indications for surgery for patients with GYN conditions: Endometriosis, Fibroids, and Adenomyosis. Please review each individual article in this series for each of the three conditions.
Adenomyosis is a condition that is much more common that OBGYN’s and patients understands. At CIGC, review of thousands of cases of hysterectomy reveal that up to 50 – 75% of patients who have needed the uterus removed have adenomyosis present. Adenomyosis is a form of endometriosis, in which the uterine lining grows into the uterine muscle, bleeds into the muscle, and progresses year to year. Symptoms of adenomyosis include severe bleeding that is heavier than any bleeding in the past. Bleeding does not have to be severe, but most patients have very serious pain associated with adenomyosis since bleeding into the muscle of the uterus is very irritating and painful. Pain usually becomes more severe with time, and back pain is a very common symptom of adenomyosis, as is bloating and distension as well as pelvic pressure. The Diagnosis of adenomyosis CANNOT BE MADE by ultrasound or CT scan. Often by ultrasound the uterus looks larger and bulkier, and when advanced some radiologists can identify the changes in the muscle of the uterus by ultrasound. MRI is the best method to make the diagnosis, bur realize can miss adenomyosis up to 25% of the time, or more. Adenomyosis is a “clinical” diagnosis, meaning that an experienced GYN surgeon can usually make the diagnosis by history of symptoms alone. The Cause of adenomyosis is thought to be due to a breakdown in the barrier between the lining of the uterus – the endometrial lining – and the muscle. This breakdown allows the lining to grow into the muscle like a spider and spread. It is very difficult to remove adenomyosis, but attempts at removal of focal adenomyosis, which is disease limited to only a certain area of the uterus, have been successful with certain techniques. Diffuse adenomyosis – disease throughout the uterine muscle – cannot be treated effectively with a method to preserve the uterus. Usually medical therapy provides short term relief for those who do not want hysterectomy.
Treatment of adenomyosis depends on whether or not patients want fertility. Those patients who have completed childbearing should give serious consideration to removal of the uterus. This does NOT mean that these patients need to undergo “complete” hysterectomy, which is removal of the uterus, the cervix, and the ovaries which results in menopause. A better option is to consider a “partial” hysterectomy, which is preservation of the ovaries. Keeping the ovaries will prevent menopause by allowing all hormones to still be produced, and even preservation of the cervix which will keep the pelvic floor intact and prevent prolapse, or “drop down” of organs through the vagina. Those patients who still want fertility can undergo removal of focal adenomyosis through the LAAM procedure. Medical therapy can be used for a limited time for early adenomyosis, but over time will not provide prolonged relief. For more information on adenomyosis and treatment options, please review the Top Five – Number 3.