Endometriosis & Adenomyosis

Endometriosis is a chronic gynaecological condition affecting millions of women worldwide, including a significant number in Australia.

It occurs when tissue similar to the lining inside the uterus, known as the endometrium, starts to grow outside the uterine cavity. This misplaced tissue can be found on the ovaries, fallopian tubes, outer surface of the uterus, and other pelvic organs.

Endometriosis is often associated with severe pain and infertility, impacting the quality of life and emotional well-being of those affected.

Causes of Pelvic Pain

The exact cause of endometriosis remains unknown, but several theories have been proposed. One of the most widely accepted theories is retrograde menstruation. This occurs when menstrual blood flows backwards through the fallopian tubes into the pelvic cavity instead of leaving the body. The menstrual blood contains endometrial cells that can implant and grow outside the uterus.

Other theories suggest that endometrial cells might spread through the bloodstream or lymphatic system, or that certain cells outside the uterus might transform into endometrial cells. Genetic factors also appear to play a role, as endometriosis tends to run in families. Additionally, immune system disorders might make the body less capable of recognising and destroying endometrial tissue growing outside the uterus.

Symptoms

The symptoms of endometriosis can vary significantly from person to person. Some women experience mild symptoms, while others suffer from debilitating pain. Common symptoms include:

Pelvic Pain: Chronic pelvic pain, often associated with the menstrual cycle, is the most common symptom. Pain can also occur during intercourse, bowel movements, or urination.
Menstrual Irregularities: Heavy periods (menorrhagia) or bleeding between periods (menometrorrhagia) are common.
Infertility: Endometriosis can cause infertility or difficulty in conceiving.
Gastrointestinal Symptoms: Bloating, diarrhoea, constipation, and nausea, particularly during menstrual periods.
Fatigue: Chronic fatigue and low energy levels are frequently reported by women with endometriosis.
Other Symptoms: Some women may experience lower back pain, leg pain, and even pain during exercise.

Risk Factors

Several risk factors may increase the likelihood of developing endometriosis. These include:

Family History: Having a first-degree relative (mother, sister, or daughter) with endometriosis increases the risk.
Menstrual Factors: Early onset of menstruation (before age 11), short menstrual cycles (less than 27 days), and heavy menstrual periods lasting longer than seven days.
Reproductive History: Never giving birth increases the risk, while pregnancy and breastfeeding seem to lower the risk.
Structural Abnormalities: Conditions such as uterine abnormalities, which affect menstrual flow, can increase the risk.
Immune System Disorders: Autoimmune diseases and other immune system disorders may contribute to the development of endometriosis.

Treatment Options

While there is no cure for endometriosis, various treatment options are available to manage symptoms and improve quality of life. Treatment approaches can be broadly categorised into medical, surgical, and lifestyle management.

Medical Treatment

Pain Relief Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help alleviate pain and inflammation.
Hormonal Therapies: These aim to reduce or eliminate menstruation, which can relieve pain and slow the growth of endometrial tissue. Options include:
- Oral Contraceptives: Birth control pills that contain both oestrogen and progestogen can regulate menstrual cycles and reduce pain.
- Progestogen Therapy: progestogen-only treatments, such as the contraceptive injection, implant, or intrauterine device (IUD), can stop menstruation and relieve symptoms.
- Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists: These drugs reduce oestrogen levels, inducing a temporary menopause-like state, which helps shrink endometrial tissue.
- Aromatase Inhibitors: These drugs reduce oestrogen production and are sometimes used in combination with other hormonal treatments.

Surgical Treatment

Laparoscopy: This minimally invasive surgery allows the surgeon to locate and remove endometrial tissue outside the uterus. It is often recommended for women with severe pain or those seeking to improve fertility.
Hysterectomy: In severe cases, a hysterectomy (removal of the uterus) may be considered, especially if other treatments have failed and the woman’s symptoms are unmanageable. The decision to remove the ovaries (oophorectomy) is more complex and should be discussed thoroughly with a gynaecologist, as it leads to early menopause.

Lifestyle and Alternative Therapies

Diet and Nutrition: Some women find that dietary changes can help manage symptoms. A balanced diet rich in fruits, vegetables, whole grains, and lean proteins, while avoiding processed foods and reducing red meat intake, may be beneficial.
Exercise: Regular physical activity can help reduce pain and improve overall well-being. Activities such as yoga, pilates, and swimming are often recommended.
Stress Management: Techniques such as mindfulness, meditation, and acupuncture can help manage stress and alleviate symptoms.
Support Groups and Counselling: Joining a support group or seeking counselling can provide emotional support and help women cope with the challenges of living with endometriosis.

Adenomyosis is a condition where the inner lining of the uterus (endometrial tissue) grows into the muscular wall of the uterus. This can lead to an enlarged uterus and painful, heavy periods. While it can coexist with endometriosis, adenomyosis is a distinct condition with its own challenges.

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How is Adenomyosis Diagnosed?

Diagnosis of adenomyosis can be challenging, as symptoms overlap with other conditions like endometriosis and fibroids. Common diagnostic tools include:

Ultrasound: A first-line imaging tool to assess characteristic uterine changes.

MRI (Magnetic Resonance Imaging): Provides more detailed images of the uterus. Can differentiate between myoma and adenomyoma.

Histopathology: A definitive diagnosis can only be made confirmed after a hysterectomy when tissue samples are examined.

Symptoms

Adenomyosis can present with a variety of symptoms, including:

Heavy or prolonged menstrual bleeding (menorrhagia).
Severe menstrual cramps (dysmenorrhoea).
Chronic pelvic pain or pressure.
Pain during intercourse (dyspareunia).
A feeling of bloating or fullness in the abdomen.

Some individuals may have no symptoms at all, and the condition is only discovered during investigations for other issues.

Risk Factors for Adenomyosis

While the exact cause of adenomyosis is not fully understood, certain factors may increase the likelihood of developing the condition:

Age: Adenomyosis is more common in women aged 35–50.

Parity: Having given birth, especially multiple times, is associated with a higher risk.

Uterine Surgery: A history of uterine surgery, such as a caesarean section or fibroid removal, may increase the risk.

Hormonal Fluctuations: High levels of oestrogen are thought to play a role.

Family History: A genetic predisposition may also contribute in some cases.

Treatment Options for Adenomyosis

Treatment is tailored to the severity of symptoms, the patient’s age, and their desire to preserve fertility. Options include:

Medical Treatment

Hormonal therapies typically using hormonal IUDs, or use of a class of medications called GnRH agonists, may be used to help symptoms.

Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief.

Minimally Invasive Procedures:

Possible utilisation of uterine artery embolisation (UAE) to reduce blood flow to the enlarged.

Definitive Treatment:

Hysterectomy (removal of the uterus) is the only definitive cure and is considered for patients with severe symptoms who do not wish to preserve fertility.

Minimally Invasive Procedures

Possible utilisation of uterine artery embolisation (UAE) to reduce blood flow to the enlarged.

Definitive Treatment

Hysterectomy (removal of the uterus) is the only definitive cure and is considered for patients with severe symptoms who do not wish to preserve fertility.

Lifestyle and Alternative Therapies

Diet and Nutrition: Some women find that dietary changes can help manage symptoms. A balanced diet rich in fruits, vegetables, whole grains, and lean proteins, while avoiding processed foods and reducing red meat intake, may be beneficial.
Exercise: Regular physical activity can help reduce pain and improve overall well-being. Activities such as yoga, pilates, and swimming are often recommended.
Stress Management: Techniques such as mindfulness, meditation, and acupuncture can help manage stress and alleviate symptoms.
Support Groups and Counselling: Joining a support group or seeking counselling can provide emotional support and help women cope with the challenges of living with endometriosis.

National approach to Endometriosis & Adenomyosis in Australia In Australia, the management of endometriosis and related conditions such as adenomyosis is guided by the National Action Plan for Endometriosis, developed by the Australian Government.

This comprehensive strategy aims to improve awareness, diagnosis, and access to care for those living with these complex conditions.

The plan focuses on enhancing public and professional education, ensuring earlier diagnosis, and improving treatment pathways. It also prioritises evidence-based clinical care and significant investment in research to better understand the causes, impacts, and treatments of endometriosis and adenomyosis.

MIGYNAE aligns with these national priorities by offering specialised, multidisciplinary care and participating in research initiatives, ensuring patients receive the highest standard of care tailored to their needs.

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