Adenomyosis Treatment Program
Adenomyosis is a benign, yet frequently disruptive gynecological condition defined by the abnormal presence of functional endometrial glands and stroma within the myometrium, the muscular wall of the uterus. Although histologically non-cancerous, this ectopic endometrial tissue retains its cyclical hormonal responsiveness, resulting in repetitive tissue remodeling, local inflammation, and increased myometrial vascularity and innervation. Over time, these processes can contribute to diffuse or focal thickening of the uterine wall, progressive uterine enlargement, and biomechanical alterations of the uterus.
The condition most commonly presents in women during their reproductive years, particularly in the fourth and fifth decades of life, and is frequently associated with multiparity. Although it is not life-threatening, adenomyosis can have a profound impact on physical well-being, emotional health, and reproductive capacity, often interfering with daily activities and interpersonal relationships. Its clinical course may be chronic and progressive, and in many cases, it coexists with other gynecological disorders, further complicating its identification.
Due to its nonspecific clinical presentation and overlap with other intrauterine or pelvic pathologies, adenomyosis is often underdiagnosed or misclassified, especially in the absence of advanced imaging or histological confirmation. As such, a high index of suspicion and comprehensive clinical evaluation are essential for appropriate management and the development of effective long-term care strategies.
Why Cuba
In Cuba, the management of adenomyosis—particularly in cases requiring surgical intervention—is guided by a patient-centered approach that prioritizes symptom control, preservation of uterine function, and the prevention of long-term complications that can impact reproductive health and overall quality of life. Treatment is offered through a structured and evidence-informed clinical pathway, with each patient undergoing a comprehensive gynecological evaluation that assesses the extent and distribution of adenomyotic tissue, uterine size, associated pelvic pathology, previous response to conservative measures, fertility intentions, and general health status. The Cuban healthcare system emphasizes personalized care planning, integrating medical and surgical strategies to optimize outcomes while ensuring accessibility and continuity of care for both national and international patients.
Causes of Adenomyosis
The exact cause of adenomyosis remains not fully understood, but several theories and risk factors have been proposed:
- Invasive Tissue Growth: Endometrial tissue may invade the uterine muscle, possibly after uterine trauma such as childbirth, cesarean section, or uterine surgery.
- Developmental Origins: Some researchers suggest the condition begins during fetal development and becomes symptomatic in adulthood.
- Hormonal Influence: Estrogen is believed to play a key role, as adenomyosis is often estrogen-dependent and may regress after menopause.
- Inflammatory Processes: Chronic inflammation of the uterus may contribute to the breakdown of the boundary between endometrial and myometrial layers.
Types and Classification
Adenomyosis is classified based on the extent and distribution of endometrial invasion into the myometrium:
Diffuse Adenomyosis
- Widespread infiltration of endometrial tissue throughout the myometrium.
- Commonly results in an enlarged, boggy uterus.
- More likely to cause severe symptoms.
Focal Adenomyosis (Adenomyoma)
- Localized nodular lesions within the uterine wall.
- Can resemble fibroids in imaging.
- May cause symptoms depending on size and location.
Cystic Adenomyosis
- Rare form involving cystic cavities within the myometrium, filled with blood or fluid.
- Typically found in younger women or adolescents.
Classification is critical for choosing appropriate treatment strategies, especially when balancing symptom relief with fertility preservation.
Symptoms of Adenomyosis
Symptoms can range from mild to severe and may progressively worsen over time. The most common clinical presentations include:
- Heavy or prolonged menstrual bleeding (menorrhagia)
- Severe menstrual cramps (dysmenorrhea)
- Pelvic pain and pressure
- Chronic lower abdominal discomfort
- Pain during intercourse (dyspareunia)
- Enlarged or tender uterus on physical examination
- Fertility challenges or miscarriage history
It’s important to note that some women with adenomyosis remain asymptomatic, particularly in the early stages.
Diagnosis of Adenomyosis
Diagnosing adenomyosis can be clinically challenging due to its non-specific symptoms and frequent overlap with other gynecologic conditions such as uterine fibroids, endometriosis, or abnormal uterine bleeding of unknown origin. Historically, a definitive diagnosis could only be made through histopathological examination of the uterus following hysterectomy.
Clinical Evaluation
- A comprehensive history and pelvic examination are often the first steps. The uterus may feel enlarged, tender, or boggy upon bimanual examination.
- Symptom patterns such as chronic pelvic pain, dysmenorrhea, or heavy menstrual bleeding may raise clinical suspicion.
Transvaginal Ultrasound (TVUS)
- First-line imaging modality
- Sonographic features suggestive of adenomyosis include:
- Heterogeneous myometrial texture
- Myometrial cysts
- Asymmetrical uterine wall thickening
- Blurred junction between endometrium and myometrium (Junctional zone)
Magnetic Resonance Imaging (MRI)
- MRI is the gold standard non-invasive diagnostic tool for adenomyosis.
- Offers superior soft tissue contrast and accurately measures the junctional zone, with a thickness >12 mm being highly indicative.
- Useful in differentiating adenomyosis from fibroids and planning fertility-preserving treatment strategies.
Sonohysterography (Saline Infusion Sonography)
- May enhance detection of intracavitary abnormalities and is helpful in identifying focal adenomyosis near the endometrial surface.
Endometrial Biopsy
- Not diagnostic for adenomyosis but may be used to rule out endometrial hyperplasia or malignancy in women with abnormal uterine bleeding.
Laboratory Testing
- Hormonal panels (e.g., TSH, FSH, estradiol) may be used to rule out other causes of abnormal bleeding but are not diagnostic for adenomyosis.
Conservative Treatment Options
For women who wish to preserve their uterus or fertility, non-surgical (conservative) management is typically the first line of treatment. These include:
- Hormonal Therapy
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
- Uterine Artery Embolization (UAE:)
- Minimally invasive radiologic procedure that blocks blood supply to adenomyotic tissue, leading to shrinkage and symptom relief.
- Most effective in focal or mild diffuse adenomyosis.
- Performed under local anesthesia and sedation, UAE involves inserting a catheter through the femoral or radial artery and delivering tiny embolic particles to block blood flow to the targeted areas of the uterus.
Surgical Treatment Options
Patients may be considered candidates for surgical intervention if they present with:
- Persistent heavy bleeding unresponsive to medical treatment.
- Severe pelvic pain or cramping interfering with daily function.
- Infertility related to focal adenomyosis.
- Rapidly enlarging uterus or suspicion of coexisting fibroids.
- Inadequate relief from hormone therapy or non-invasive options.
Fertility preservation, age, symptom severity, comorbidities, and personal preference are all carefully considered before selecting a surgical approach.
Adenomyomectomy (Uterus-Sparing Surgery)
Adenomyomectomy is a specialized surgical procedure aimed at removing focal adenomyosis—often referred to as an adenomyoma—while preserving the rest of the uterus.
- Particularly valuable for women of reproductive age who wish to retain fertility or avoid hysterectomy.
- The procedure involves precise excision of the diseased myometrial tissue.
- Technically challenging due to ill-defined margins and risk of uterine rupture in future pregnancies.
- Often performed using laparoscopy (minimally invasive).
Hysterectomy (Definitive Surgical Option)
- Complete removal of the uterus.
- Considered the only definitive cure for adenomyosis.
- Recommended for women who:
- Have completed childbearing.
- Have diffuse adenomyosis.
- Have not responded to other therapies.
- May be performed via:
- Laparoscopic Hysterectomy (Minimally Invasive)
- Performed using small abdominal incisions and a laparoscope (a thin, lighted camera), allowing for internal visualization and precise removal of the uterus.
- Associated with less postoperative pain, shorter hospital stays, faster recovery, and minimal scarring.
- Ideal for patients with moderate uterine size, localized adenomyosis, or those desiring a less invasive surgical option with rapid return to normal activities.
- Vaginal Hysterectomy (Minimally Invasive)
- The uterus is removed entirely through the vaginal canal, without any abdominal incisions.
- Considered the least invasive surgical option when feasible, with short operative time, low complication rates, and rapid postoperative recovery.
- Best suited for patients with normal-to-moderately enlarged uteri, pelvic organ prolapses, or no history of extensive abdominal surgeries.
- Often performed under regional or general anesthesia and may require minimal instrumentation.
- Laparoscopic Hysterectomy (Minimally Invasive)
- Abdominal Hysterectomy (Open Surgery)
- Performed through a horizontal or vertical abdominal incision, providing direct access to the pelvic organs.
- Reserved for patients with very large uteri, severe adhesions, coexisting pelvic pathology (e.g., large fibroids, extensive endometriosis), or previous failed minimally invasive attempts.
- Involves longer recovery time (typically 4–6 weeks), greater postoperative pain, and a higher risk of complications, but allows for comprehensive exploration of the pelvis when needed.
- Remains a necessary option in complex or high-risk surgical cases where minimally invasive methods are not safe or practical.