November 11, 2017
I remember writing my Royal College of Physicians exam to get certified as an obstetrician/gynecologist and thinking "please, please don't ask me much about adenomyosis." Adenomyosis is a fairly uncommon disease of the uterus that is hard to diagnose, hard to treat and causes a slew of terrible symptoms like pelvic pain, heavy periods and infertility. In the past decade or so since I wrote my exam we've learned a lot more about adenomyosis so I am less afraid of being asked questions. I recently spoke as an expert on the topic at a provincial gynecology meeting so I guess now I am now a bit more confident on the topic!
The uterus has essentially two parts: the muscle wall called the myometrium and the lining, called the endometrium. They are separated by a thin dividing wall.
If the endometrium breaks through this wall and is found embedded into the myometrium this is called adenomyosis. In adenomyosis, the myometrium enlarges, gets soft and bleeds internally every month. Also, the lining, or endometrium, in women with adenomyosis is less healthy than normal making it harder for an embryo to implant. This causes infertility.
We can diagnose adenomyosis by ultrasound, MRI or by cutting up the uterus and looking at it under a microscope. Historically it has been hard to diagnose it by ultrasound, but now that we do transvaginal scanning with better equipment we can pick up the endometrium in the myometrium fairly confidently by ultrasound.
What do we do if we find it? If the reason you are looking is infertility, we can suppress the endometrial lining using a medication called a GnRH agonist (e.g. Lupron). This medication blocks estrogen production which is what causes adenomyosis to grow. Now, it also blocks ovulation so a GnRH agonist won't help you get pregnant. How we use it is in IVF treatment prior to a frozen embryo transfer.
So, a woman with adenomyosis will undergo IVF but NOT have the embryos put into her right away (fresh embryo transfer). Instead the embryos are frozen and the woman treated for 2-3 months with a GnRH agonist to suppress the adenomyosis. Once it is suppressed we then put the embryos in the uterus. Women don't really like this as it causes yet another delay in a treatment that already feels long, BUT it gives women a 10-15% higher chance of getting pregnant than if you don't use the GnRH agonist, so it's worth it in the long run.
When you first meet an Olive physician you will almost always have a transvaginal ultrasound - either at the first visit or shortly thereafter. This ultrasound looks for lots of things and adenomyosis is one of them. Don't hesitate to ask your doctor if you have it - they can diagnose it right there on the spot. It's important to know - every little detail matters in infertility treatment.
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