Adenomyosis and hormones: what you need to know

Adenomyosis can cause heavy, painful periods and can be affected by hormone changes

• Many women who have adenomyosis will also have endometriosis
• Symptoms may get worse during perimenopause but can resolve in menopause
• Treatments include medication, hormones and surgery and will depend on the severity of your symptoms

What is adenomyosis?

Adenomyosis occurs when tissue similar to the tissue that normally lines your womb (endometrial tissue) grows into the muscular wall of your womb (uterus).

This tissue continues to act in the same way as the lining of your womb does and thickens, breaks down and then bleeds, during your period. This can lead to heavy, painful periods and an enlarged uterus. You may experience pain at other times to your periods too.

Adenomyosis is a relatively poorly understood condition by doctors and researchers, but more information is being discovered all the time.

RELATED: Heavy periods during the perimenopause: what you need to know

How common is adenomyosis?

It is difficult to know exactly how many women are affected by the condition, as there has been little research about it and the condition may not cause symptoms at all in some women. However, the figures around the number of women affected are increasing as diagnosis improves through better scanning techniques.

A UK study of almost 1,000 women having scans for gynaecological problems including infertility and irregular bleeding found that almost 21% had adenomyosis [1]. Meanwhile a large US study suggested almost 1% of women (0.8%) could be affected, rising to 1.5% for women aged between 41 and 45 years [2].

RELATED: Hormonal changes and endometriosis: busting myths and seeking help

What are the causes of adenomyosis? 

The cause of adenomyosis is not yet fully understood. It may be related to more inflammation in your body, which can occur for various reasons.

RELATED: Endometriosis and hormones

Who does adenomyosis affect?

This is another emerging area of research, but it seems that there are certain factors that put you at higher risk of adenomyosis. These include multiple pregnancies or prior surgery to your womb.

What are the symptoms of adenomyosis?

According to NICE guidance on heavy menstrual bleeding, healthcare professionals should consider adenomyosis if you have significantly painful periods, and have a large, tender uterus on examination. Adenomyosis can cause heavy periods that last a long time, a feeling of pressure in your abdomen and bloating.

Other symptoms include pelvic pain, pain during sex and infertility. However, you could also have the condition and have few or no symptoms at all.

RELATED: Vaginal bleeding during perimenopause and menopause

How does adenomyosis differ from endometriosis?

With adenomyosis, the tissue grows within the muscular walls of your womb. In endometriosis, tissue similar to the lining of your womb grows outside the uterus and may involve the ovaries, fallopian tubes, pelvic area and bowel.

Adenomyosis is more likely to cause heavy period bleeding than endometriosis, and endometriosis is often associated with other symptoms [3].

Research suggests that if you have one of these conditions, you are more likely to have the other. One study in Germany that looked at MRI scans found that 80% of women with adenomyosis had endometriosis, and 91% of women with endometriosis had adenomyosis [4].

RELATED: My Story: Why did I suffer for so many years with endometriosis?

How is adenomyosis diagnosed?

If you have symptoms of adenomyosis, your first step should be to make an appointment to see your GP. They should ask you about the nature of your period bleeding, your other symptoms, such as pelvic pain, and the impact on your quality of life.

Your GP will likely want to examine you to see if you have a bulky, tender uterus, and may advise a blood test to check your haemoglobin (blood count) and iron levels to check that you have not become anaemic or have a low iron level from heavy bleeding. If your doctor thinks you are likely to have adenomyosis they are likely to refer you for a transvaginal ultrasound scan [5].

This is where a small ultrasound probe is carefully passed into your vagina, so that your womb can be more closely studied. Internal examinations may cause some discomfort, but don’t usually cause any pain and tend to last about 5-10 minutes.

A magnetic resonance imaging (MRI) scan may be needed in some cases. MRI scanning was previously considered the best way to establish a diagnosis of adenomyosis, but ultrasound now is steadily becoming the preferred imaging, thanks to its increasing accuracy and ease of access.

How do perimenopause and menopause affect adenomyosis?

During perimenopause there are often significant fluctuations in your hormone levels, which can make your periods unpredictable – they may become more or less frequent, and you may bleed for longer. This means that if your periods are heavy and painful from adenomyosis, you may experience this more if your cycle is getting shorter and your periods are longer.

The perimenopause can last for up to 10 years before your periods stop altogether and it most commonly occurs when a woman is in her forties.

How is adenomyosis treated?

If you are struggling with the symptoms of adenomyosis, treatments that can help include medication, devices and surgical options, which you should talk through with your healthcare professional.

Medicines that regulate your hormones can help with symptom control.

Mirena coil

One treatment option for many women is an interuterine system (IUS), known as the Mirena coil. This a small, T-shaped plastic device that is placed in your womb by a doctor or nurse. The Mirena coil steadily releases a type of progestogen and can be used to reduce heavy, painful periods and improve symptoms of adenomyosis.

Once in place it is effective for five years. It can take at least six months for the Mirena to improve your symptoms.

RELATED: The Mirena coil: everything you need to know

Prescription and over-the-counter medication options

If the Mirena coil doesn’t ease symptoms, medication options often include tranexamic acid, a prescription medication that controls bleeding, and anti-inflammatory medication to relieve pain, such as ibuprofen.

Oral contraceptive pill

Oral hormonal options, such as the combined oral contraceptive pill (which contains both oestrogen and progestogen) or the progestogen only pill, known as the mini pill, can stop your periods altogether, which can be beneficial if you have painful periods. However, they contain synthetic hormones which are different to the natural hormones in your body.

Some doctors prescribe hormone blocking drugs such as Zoladex but this stops all your hormones being produced so it is preferable to have add-back HRT with these treatments so you can have a steady dose of hormones.

Surgical options

If none of these options work for you, or your symptoms are very severe, a surgical approach could be considered. One option is a hysterectomy, which is the removal of the womb. You should only consider surgical options after discussing the risks and benefits with your doctor.

RELATED: Podcast: Raising awareness of endometriosis and surgical menopause with Vicki Shattock

Can I take HRT if I have adenomyosis?

HRT is the first-line treatment for the management of perimenopause and menopause symptoms.

There are different types of oestrogen, and they work differently in your body. Some women find that the synthetic oestrogen in contraceptives and some types of HRT can flare up and worsen their adenomyosis whereas taking oestradiol in body identical HRT does not have these effects.

Continuous HRT, when oestrogen and progesterone (or a progestogen) are given continuously throughout your cycle, are usually preferable. The Mirena coil can be used as well as taking continuous progesterone. Some women find that taking testosterone too improves symptoms such as mood, memory, concentration and libido and can improve pain associated with adenomyosis too.

RELATED: Sequential and continuous HRT: what’s the difference?

In menopause, when your periods have stopped all together, all the same options of continuous HRT should be available to you.

Some women may find when they first start HRT, their adenomyosis symptoms can return, this can often be improved by adjusting your HRT dose and does usually settle with time.

RELATED: What to expect when you start HRT

It is important to mention any bleeding or pain you are experiencing to your healthcare professional, who should be able to help you adjust your HRT to get the maximum benefit.

References

1. Upson, K, and Missmer, S.A, (2020), ‘Epidemiology of adenomyosis’, Seminars in Reproductive Medicine, 38 (2-03), pp.89-107. doi: 10.1055/s-0040-1718920

2. Yu, O. et al. (2020), ‘Adenomyosis incidence, prevalence and treatment: United States population-based study 2006-2015’, American Journal of Obstetrics and Gynecology, 223 (1), e1-94. doi: 10.1016/j.ajog.2020.01.016

3. NHS: Endometriosis

4. Leyendecker G., Bilgicyildirim A., Inacker M., et al. (2015), ‘Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study’, Archives of Gynecology and Obstetrics, 291(4), pp.917-32. doi: 10.1007/s00404-014-3437-8

5. NICE Guidance [NG88] (2021), Heavy menstrual bleeding: assessment and management

6. Royal College of Obstetricians and Gynecologists, ‘Endometrial ablation – recovering well’