Why is Adenomyosis Difficult to Diagnose?

Typical symptoms of adenomyosis are heavy menstrual bleeding, severe period pain, chronic pelvic pain, bulky uterus, and sub-fertility. However, the symptoms of adenomyosis are non-specific, meaning these symptoms can be caused by a variety of other pathologies. For example, fibroids can also cause heavy menstrual bleeding and period pain, as well as bulky uterus; we tend to think of endometriosis if a woman suffers from severe period pain. In terms of subfertility, there is a long list of other potential causes.

Unless you have a good quality transvaginal ultrasound, adenomyosis is quite often missed. Even in an experienced ultrasound practice, adenomyosis can be missed if fibroids are also present. MRI is more accurate, less operator dependent, and won’t be confused with fibroids.

Additionally, there is no reliable blood test for adenomyosis. Biopsy has not shown to be useful.


How Can We Reliably Diagnose Adenomyosis?

The most definitive diagnosis is on pathologic examination of the whole uterus after hysterectomy. Adenomyosis can be present in up to 70% of hysterectomy specimen. In other words, adenomyosis is much more common than we realize in women who are suffering and symptomatic enough to warrant a hysterectomy.

Studies have shown that transvaginal ultrasound (TVUS) performed in academic centres that specialised in women’s health imaging can be almost as accurate as MRI. In real-world practice, we have seen 71% of adenomyosis were missed on TVUS. MRI is less operator dependent, and can easily differentiate fibroids from adenomyosis, and able to detect subtle adenomyotic changes.

However, in Australia, MRI of the uterus looking for adenomyosis is not funded by Medicare. Someone had a skiing injury whilst having fun can have a Medicare-funded MRI of the knee; yet women who have been suffering for years from debilitating symptoms cannot get a Medicare-funded MRI of their uterus. If this is not gender inequality, I don’t know what else is?

Many modern-day career women or busy mothers do not want hysterectomy anymore. They are seeking less invasive non-surgical therapies.

For many women in the past, failing conservative medical therapy for heavy menstrual bleeding and period pain, hysterectomy might be the only way to treat their debilitating symptoms.


Why is MRI More Accurate Than Ultrasound in the Diagnosis of Adenomyosis?

MRI is less operator-dependent and has a better delineation of different body tissues. Both fibroid and adenomyosis are common and they can coexist. Presence of fibroids makes it difficult for ultrasound to detect adenomyosis. MRI is far better at differentiating fibroids from adenomyosis. Unfortunately, pelvic MRI for benign, non-cancerous diseases is not funded by Medicare in Australia.


How Does UAE Kill Adenomyotic Tissue But Spare the Normal Uterine Wall?

A non-pregnant uterus is only about 60-100 grams in weight. During pregnancy, the uterus can enlarge enormously, carries with it 40 times in blood flow, opening up numerous blood vessels that were normally dormant. At UAE, PVA (polyvinyl alcohol) particles are injected to block the small blood vessels supplying the uterus. Normal uterine tissue has plenty of dormant blood vessels to recruit to remain viable and alive. However, the adenomyotic tissuedoes not have the capacity to recruit dormant vessels and will be starved to death without oxygen and nutrients. 


Why Would Endometrial Ablation Worsen Period Pain?

Endometrial ablation uses heat energy to destroy the inner lining of the uterus so that a woman will no longer have periods. The process can seal off endometrial sinuses and make period pain worse. After ablation, the heavy menstrual bleeding might be improved, but some women have an exacerbation of period pain after ablation. Ablation is helpful for women with a very superficial type of adenomyosis involving a depth of a few millimetres. Deep adenomyotic tissue cannot be adequately treated with endometrial ablation.


Can adenomyosis be removed surgically? 

Generally speaking, adenomyosis is not suitable for surgical removal. Adenomyosis is a diffuse infiltrative process. Unlike fibroids, which can be easily separated from the normal uterine wall, adenomyotic tissue does not have a clear buoundary with the normal myometrium.

Surgeons find it difficult to determine where adenomyosis stop and where normal myometrium starts. The removal is either incomplete, leaving behind adenomyositic tissue which can continue to grow and cause problems, or a larger than necessary amount of normal myometrium around the adenomyois might have to be removed.

Surgeons might have been mislead by incorrect ultrasound diagnosis and inadvertently went ahead with surgery, thinking that the aim was to remove a “fibroid”, then realized that the lesion cannot be separated out from uterus. I have seen cases that surgery was abandoned and women subsequently referred for embolisation.


Can I still get pregnant after UAE?

We know after UAE for adenomyosis, there are more than 95% chances the women get to keep her uterus. However, currently we don’t know how good the uterus is for pregnancy. All we can say is: pregnancy is possible, but might to be complicated.

We know that women with adenomyosis might be difficult to get pregnant. Hormonal stimulation required for IVF cycles can stimulate and worsen adenomyosis.

Pregnancy in women with adenomyosis is a complex and interrelated issue. We know simple and complicated pregnancies like Ceasarian section, miscarriages, termination of pregnancy and previous D&C procedures are associated risks for development of adenomyosis.  


Why Are You So Passionate About Adenomyosis as an Interventional Radiologist?

Good question. I am not even a gynaecologist.

Over the last 10 years, I have help hundreds of women suffering from heavy menstrual bleeding (HMB) and severe period pain using a non-surgical treatment called uterine artery embolisation (UAE). Many were told they have fibroids, in fact when we check with MRI, the real cause of the women’s symptoms were adenomyosis. Many of these women have been suffering from debilitating symptoms for years and were told to have “just a few fibroids” or “ unremarkable uterus”. Some have had endometrial ablation for heavy menstrual bleeding and soon find out that the period pain skyrocketed afterwards.

Many were thought to have endometriosis, yet laparoscopy were normal and the cause of the period pain was from adenomyosis indeed. Worst were those women who have gone through and failed multiple cycles of IVF, without knowing that they have underlying adenomyosis as the cause of their subfertility.

It’s a shame that these women have to suffer years of debilitating symptoms without the correct diagnosis. It’s BAD if these women were given inappropriate treatments.

I believe we can do a lot better, in terms of diagnosis and treatment, for women suffering from adenomyosis.


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