In this episode of PodMD, experienced Endo-Gynaecologist, Advanced Laparoscopic Surgeon and General Gynaecologist Dr Dan Krishnan will be discussing the topic of adenomyosis, including what adenomyosis is, the main risks of the condition, the treatment options available, the likelihood of recurrence, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Dan Krishnan
Dr Dan Krishnan is an Endogynaecologist and General Gynaecologist providing care in Liverpool and Ashfield. Dan completed his medical degree from The University of Queensland in 2011, his passion for Obstetrics and Gynaecology landed him a registrar position at King Edward Memorial Hospital for Women, Perth.
Dr Krishnan spent two years at the prestigious Sydney Minimally Invasive Gynaecology Surgery (SMIGS) unit, an AGES-accredited fellowship at the Sutherland Hospital where he now holds a staff specialist position. Upon completing his fellowship and obtaining his FRANZCOG, Dan decided to venture further into complex pelvic surgery at Westmead Hospital as a Gynaecological Oncology Fellow. He currently holds a staff specialist position at Liverpool Hospital, where he leads Endogynaecology clinics and surgeries.
Today, we’ll be discussing the topic of Adenomyosis, which is the second in a four-part series called ‘The Women in Pain’.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Dan, thanks for talking with us on PodMD today.
Dan : Thank you for having me.
The topic of today’s discussion is adenomyosis. Dan, can you describe for our listeners what adenomyosis is?
Dan: So the term adenomyosis comes from a few different words and combination. So just to split it into 3, adino would mean gland, myo would mean muscle and osis would mean condition. It’s basically a condition of a glandular muscular structure that is inside the uterus. In short, Adenomyosis is a condition of the uterus where cells similar to the lining on the inside of the uterus is also present within the muscular wall of the uterus. So that is adenomyosis.
Most often women with adenomyosis will also have endometriosis. However, there are different conditions. We spoke about endometriosis at length in our first podcast of the Woman In Pain. This time we will focus on adenomyosis, which is related to endometriosis. However, they are both very different conditions.
Just to contrast the difference with endometriosis, the cells are similar to the one that lines the uterus where they are usually found outside the uterus and fallopian tubes, the ovaries, and the tissue lining the pelvis and the peritoneum. With adenomyosis, the endometrial lining occurs inside the muscle layer at the back wall at the front wall or the entire uterus.
If adenomyosis is concentrated in one area, it can lead to a non-cancerous growth called adenomyoma. Generally, this is quite rare. We most often find diffuse adenomyosis where the whole uterus is affected.
How would a patient with adenomyosis typically present?
Dan: So the most common symptom that patients often present as an extremely painful periods. Women who’ve had children would often come presenting to my clinic telling me that they feel like every time they have a period, it feels like labour pain. The contraction of the uterus can be so severe it is exactly like labour pain.
They often also have heavy periods or heavy menstrual bleeding. Which can lead to severe iron deficiency or anaemia. Occasionally there is also symptoms of endometriosis, and these symptoms overlap, usually associated with painful intercourse. Even without pain, patients with adenomyosis sometimes can have a pelvic fullness where the uterus is bulky and tender.
What are the risks of the condition?
Dan: So the cause of adenomyosis is unknown. There are a few theories. The lining of the cells grow into the muscle layer due to surgery, so sometimes we find women with previous uterine surgery are prone to more adenomyotic changes of the uterus. Sometimes the inflammation of the uterine lining can occur after childbirth and which is, which causes women with previous childbirth to present with severe menstrual bleeding and cramps.
Oestrogen is often needed for adenomyosis to occur. It’s usually a disease that affects women of reproductive age and the general age for adenomyosis would be women age between 30 and 50 years. It’s rare in the postmenopausal stage, however, symptoms can still persist.
What are the treatment options?
Dan: So, the first treatment option is often going to be conservative options where we find alternative treatments to pain can sometimes help patients. It starts with weight loss exercise in some conditions acupuncture may help some symptoms. Meditation is also known to help adenomyosis. These are treatment options for very mild symptoms and may not be effective with severe adenomyosis. By the time I see patients for a gynaecological consultation, they often need further treatment.
With regards to medical options for treatment of adenomyosis, we have first of all to start with simple analgesia or the non-hormonal options. Like endometriosis, anti-inflammatory treatment often helps adenomyosis. Something specific that we use for adenomyosis can be buscopan, which is usually used for stomach cramps. It can sometimes help the crampy painful menstrual pain that is associated with adenomyosis. Simple paracetamol is also known to help adenomyosis pain.
When we speak about hormonal options, any option to reduce the frequency and length of menstruation is known to help adenomyosis. Sometimes we can put patients on the combined oral contraceptive pill and to control the menstruation to occur less frequently, often known as tricycling, to reduce the frequency of menstruation in a year, restricting it to three to four times a year.
Another very common option is the insertion of the Marina intrauterine contraceptive device. These two options are often common for patients who are fertility preserving with severe adenomyosis. The other option is the surgical option. Once my patients have completed their family, I often offer a total laparoscopic hysterectomy for the removal of the uterus via keyhole surgery. As this is the this is found to be most effective for adenomyotic pain symptoms, that is, if they have completed their family. If they have not completed their family, we do offer a hysteroscopic examination of the uterus and a Marina insertion at the same time.
Rarely we would sometimes offer an adenomyomectomy if the adenomyosis is focused in one section of the uterus and mimics a fibroid. I would like to know that. Benomyl vector many is a procedure that is still. Being researched on extensively and we still do not have enough data to support this to offer this routinely to patients, it is often offered on a case to case basis.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Dan: As previously mentioned, very rarely patients would be eligible for adenomyomectomy which is a procedure where key hole surgery is performed on a patient. The uterus is clearly inspected and parts of the uterus is shaven off and the uterus is stitched back together. This is for patients wanting fertility in the future and it’s often for patients with focal adenomyosis. Other new developments that’s been researched on is uterine artery embolization, where blood supply to the uterus is blocked to reduce the size and burden of the uterus, containing adenomyotic [inaudible].
This technique usually reduces bleeding, however, it can have complications. It is not recommended for patients who are planning a pregnancy. It’s often a conservative approach for patients declining a total laparoscopic hysterectomy or for patients who would prefer a minimally invasive, less invasive approach to treating adenomyosis. It is known to reduce bleeding. However, some patients, despite the uterine artery embolization, can still have pain.
Are there any warning signs a GP or their patient can look out for?
Dan: I always say this in my podcast, menstrual pain is never meant to be normal. Pelvic pain during menstruation should be warning signs to GPS for an investigation. Heavy menstrual bleeding is also never normal, and when patients report unspecified pelvic fullness, this would warrant an investigation by the general practitioner, starting with a routine pelvic ultrasound.
What is the likelihood of recurrence of the condition?
Dan: The good thing about adenomyosis is once a patient, has completed her family and has had a laparoscopic hysterectomy, they are usually symptom free. It does not recur because it’s a condition that affects within the muscular walls of the uterus. So upon removal, it treats the disease. In some cases, when it is fertility preserving, we insert a Marina contraceptive device that can fail.
Occasionally, patients would report severe rejection, which is usually shown by excessive cramps and severe pain, and we might need to remove the Marina as they are not reacting well to it. Sometimes the Marina bite might be expelled by severe adenomyosis cramps. In such conditions, the pain of adenomyosis will return. And can cause severe issues to the patient.
When should a GP refer?
Dan: The uterus is sometimes tender on vaginal examination. During a routine speculum and cervical screening test being performed by the GP, any tenderness should prompt further investigation. Tender uterus, or enlarged uterus, is never normal and should prompt an urgent pelvic ultrasound. Adenomyosis unfortunately, can be difficult to diagnose because there is no one routine test that can confirm it. It is usually a trans vaginal ultrasound that help delineate the uterus and show us the muscular layer of the uterine cavity.
It is best done by a specialist women’s ultrasound centre that is better at picking up adenomyosis. Occasionally we can perform MRIs. However, the final diagnosis of adenomyosis is often histopathological when the specimen has been removed at hysterectomy and has been sent for histopathology by the pathologist. In short, any pelvic fullness, any abnormal bleeding and severe menstrual cramps should prompt a GP to refer to a gynaecologist.
What role does the GP play in the treatment of the condition?
Dan: The most important role for a GP is to identify symptoms of adenomyosis. Specifically, when patients say, ‘every time I’m having a period, I feel like I’m in labour’. That is the first sign of adenomyosis. It is important to spread awareness of adenomyosis as well amongst patients. A detailed history on menstrual abnormalities is vital, particularly when patients come in for, well, women’s check. In short period, pain is never normal and should always prompt awareness for adenomyosis.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on adenomyosis?
Dan: Period pain is never normal. Pelvic fullness is never normal. And any heavy menstrual bleeding should be investigated with a prompt referral to a gynaecologist.
Thanks for your time and the insights you’ve provided.
Dan: Thank you so much for everyone’s time