Beyond cramps: Understanding adenomyosis and its impact on women’s health
Doctors warn that chronic period pain is often a symptom of underlying conditions such as endometriosis and adenomyosis. Normalising suffering delays diagnosis, worsens outcomes and costs women their health and livelihoods.
What you need to know:
- Persistent painful and heavy periods may signal adenomyosis, an often overlooked but treatable uterine condition.
- Advances in imaging are helping detect adenomyosis earlier, improving diagnosis and management for affected women.
Many women are often told that painful or heavy periods are something they must endure. While mild discomfort during menstruation can be normal, persistent or severe pain and excessive bleeding may signal an underlying medical condition. One commonly overlooked cause is adenomyosis.
Adenomyosis occurs when tissue that normally lines the uterus (the endometrium) grows into the muscular wall of the uterus. This leads to an enlarged, inflamed, and tender uterus, often resulting in heavy and painful periods. It is important to distinguish adenomyosis from related conditions. Endometriosis occurs when similar tissue grows outside the uterus, affecting organs like the ovaries or pelvic lining. Fibroids, on the other hand, are non-cancerous muscle growths that form solid masses within or around the uterus. These conditions can coexist, which sometimes makes diagnosis more complex.
The exact cause of adenomyosis is not fully understood. Like endometriosis, it is thought to arise from multiple contributing factors rather than a single cause. One widely accepted theory suggests that disruption of the boundary between the uterine lining and the muscle layer allows endometrial cells to grow into the muscle over time. Another theory links the condition to repeated uterine injury. Procedures such as cesarean section, dilation and curettage, or other uterine surgeries may weaken this boundary, making it easier for the lining cells to invade the muscle.
Hormones, particularly oestrogen, play a significant role. Adenomyosis is an oestrogen-dependent condition, meaning it tends to develop during the reproductive years and often improves after menopause when oestrogen levels decline. Inflammation and abnormal healing processes within the uterus are also believed to contribute.
Adenomyosis is likely more common than previously thought, but it has historically been difficult to measure accurately. In the past, it was mainly diagnosed after hysterectomy, when the uterus could be examined under a microscope. As a result, earlier data focused on women already undergoing surgery rather than the general population.
With advances in imaging such as ultrasound and magnetic resonance imaging (MRI), adenomyosis is now being identified more frequently and in younger women, sometimes even in their 20s. It may also contribute to fertility challenges in some cases. Overall, it most commonly affects women of reproductive age and is uncommon after menopause.
Several factors may increase the likelihood of developing adenomyosis. These include prior uterine surgery (such as cesarean section or dilation and curettage), multiple pregnancies, increasing age during reproductive years, and coexisting conditions like endometriosis or fibroids. Prolonged exposure to oestrogen for example, starting menstruation at a younger age or having shorter cycles may also play a role. However, the condition can still occur in women without any known risk factors.
Symptoms of adenomyosis vary widely. In some cases, it may be detected incidentally during routine check-ups, but most women experience noticeable symptoms. Heavy menstrual bleeding is one of the most common. Women may find themselves soaking through pads quickly, needing frequent changes, or passing blood clots. This is due to both the enlarged uterus and increased blood flow.
Painful periods are another hallmark symptom. The pain is often deeper and more intense than typical menstrual cramps, may begin before menstruation starts, last longer, and worsen over time. Some women also report that standard pain medications become less effective.
Chronic pelvic pain may occur even outside of menstruation, presenting as a constant dull ache or a feeling of pelvic heaviness. Some women also experience a sense of fullness or pressure in the lower abdomen, especially when the uterus is enlarged. Infertility can be a concern as well, although this is often influenced by coexisting conditions such as endometriosis or fibroids. While asymptomatic cases are possible, they are relatively uncommon.
Diagnosis of adenomyosis involves a combination of medical history, physical examination, and imaging. A detailed history helps assess the severity of symptoms, menstrual patterns, and any changes over time. Fertility concerns and previous uterine procedures are also considered.
During a pelvic examination, the uterus may feel enlarged and tender. Unlike fibroids, which often present as distinct lumps, adenomyosis usually causes a more uniform enlargement, although localised areas may sometimes be detected.
Imaging
Imaging plays a key role in diagnosis. A transvaginal or pelvic ultrasound is typically the first step and may reveal thickening of the uterine wall, small cystic spaces, or an uneven muscle texture. However, results can vary depending on timing within the menstrual cycle and the skill of the operator. MRI provides more detailed imaging and is particularly useful when the diagnosis is unclear or when distinguishing adenomyosis from other conditions. It also helps guide treatment decisions.
There are no specific blood tests to diagnose adenomyosis. However, tests such as a full blood count may be performed to check for complications like anemia caused by heavy bleeding, or to rule out other conditions. Treatment depends on symptom severity and whether the woman wishes to have children. If adenomyosis is present but not causing symptoms, no treatment may be necessary, and regular monitoring may be sufficient.
For symptomatic women, treatment usually begins with medication. Pain relievers such as non-steroidal anti-inflammatory drugs can help reduce both pain and bleeding during menstruation. Other medications may also be used to decrease the amount and duration of bleeding.
Hormonal therapies are commonly used. Combined oral contraceptive pills can help regulate menstrual cycles and reduce symptoms. Progesterone-based treatments are another option. One of the most effective treatments is the hormonal intrauterine device, such as Mirena. This device works within the uterus to thin the lining, leading to reduced bleeding and pain over time. Many women experience significant relief with this method.
It is important to note that these treatments manage symptoms but do not cure the condition. Symptoms may return if treatment is stopped. For women who have completed childbearing and continue to experience severe symptoms despite medical treatment, hysterectomy is the definitive option. Removal of the uterus eliminates the source of the problem. However, it is a major surgical procedure that requires careful consideration. Additionally, if other conditions such as endometriosis are present, some symptoms may persist after surgery.
Uterine artery embolisation may be considered in selected cases. This procedure reduces blood flow to the uterus and can improve symptoms, although it is generally not recommended for women who wish to conceive in the future.
For women who want to preserve fertility, management can be more complex. In certain cases, surgery to remove affected areas while preserving the uterus may be attempted, though this is technically challenging and not always suitable, especially when the condition is widespread. Assisted reproductive techniques such as in vitro fertilisation may also form part of the treatment plan.
The writer is Consultant Obstetrician Gynaecologist at Aga Khan University Hospital, Nairobi.
