Understanding Endometriosis and Adenomyosis

Endometriosis and adenomyosis are chronic, complex conditions involving abnormal tissue growth within the pelvic cavity (and sometimes beyond in the case of endometriosis).

While they share some similarities, they are distinct conditions with unique challenges.

This guide overviews the key differences and similarities between endometriosis and adenomyosis and how these conditions can impact fertility.

What is endometriosis?

Endometriosis is a condition in which endometrial-like tissue grows outside the uterus. Its cause is unknown, and there’s currently no cure for the disease.

Endometriosis isn’t just a “menstruation disease;” it’s a whole-body disorder that can affect a person’s entire life, from physical health to emotional well-being.

Types of Endometriosis

The American Society for Reproductive Medicine (ASRM) classifies endometriosis into four stages based on the number of lesions present, their size, and the extent of involvement.

These stages range from Stage I (minimal) to Stage IV (severe).

It’s important to note that the stage classification of endometriosis does not necessarily correlate with the severity of symptoms or the impact on an individual’s quality of life.

The Endometriosis Foundation of America (EndoFound) developed a classification system to help patients better understand the ASRM staging system.

The EndoFound classification system categorizes endometriosis into four categories:

Category I: Peritoneal Endometriosis

Peritoneal endometriosis refers to the presence of endometriosis lesions on the peritoneum, which is the lining of the abdominal cavity.

Category II: Ovarian Endometriomas (Chocolate Cysts)

Ovarian endometriomas, or chocolate cysts, are cystic structures filled with dark brown endometrial fluid that develop on the ovaries. These cysts can vary in size, cause pain and discomfort, and affect the ovarian function.

If the cyst ruptures, it can spread endometriosis to surrounding areas.

Category III: Deep Infiltrating Endometriosis I (DIE I)

Deep infiltrating endometriosis I refers to deep lesions that penetrate the surrounding tissues, such as ovaries, rectum, or other pelvic structures.

Category IV: Deep Infiltrating Endometriosis II (DIE II)

When endometriosis grows on organs inside and outside the pelvic cavity, it’s classified as deep infiltrating endometriosis II. These areas may include the bowels, appendix, diaphragm, heart, lungs, and, in severe cases, the brain.

How do you know if you have endometriosis?

There’s no definitive way to diagnose endometriosis without undergoing a diagnostic laparoscopy, a surgical procedure in which a fiber-optic instrument (laparoscope) is inserted through the abdominal wall to view the stomach or pelvic area.

However, a few telltale signs and symptoms may indicate the possibility of endometriosis.

These include:

• Painful periods (dysmenorrhea)
• Chronic pelvic pain, which may worsen during menstruation
• Painful intercourse (dyspareunia)
• Infertility or difficulty getting pregnant
• Painful bowel movements or urinary symptoms during menstruation
• Constipation
• Chronic fatigue
• Neuropathy
• Excessive or heavy bleeding during periods (menorrhagia)

Risk Factors for Endometriosis

People with the following risk factors may be more likely to develop endometriosis:

• Family history of endometriosis
• Starting menstruation at an early age (before age 11)
• Never giving birth
• Having a short menstrual cycle (less than 27 days)

Management and Treatment Options for Endometriosis

There’s no cure for endometriosis; however, there are ways to manage and treat the symptoms associated with the condition, including:

Pain Management

• Over-the-counter pain relievers: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help with pain, though long-term use may cause side effects.
• Prescription Pain Medication: Stronger pain relievers may be needed in some cases.

Hormonal Therapy

• Hormonal birth control: Combined estrogen and progesterone contraceptives (pills, rings) suppress ovulation and reduce estrogen levels, slowing down endometriosis.
• Progestins: Progesterone-only birth control pills, injections, or IUDs achieve similar effects as combined oral contraceptives.
• GnRH Analogs: These medications temporarily shut down hormone production, mimicking menopause, but shouldn’t be used for an extended period of time due to potential side effects.

Surgery

• Laparoscopy: Minimally invasive surgery using a laparoscope to visualize and remove or destroy endometriosis

What is adenomyosis?

Adenomyosis is when endometrial tissue grows into the myometrium or the muscle wall of the uterus. Often referred to as the “evil twin sister” of endometriosis, adenomyosis shares some similarities with endometriosis but has its own unique characteristics.

Adenomyosis typically occurs in women who are in their 30s and 40s and have had children. However, it can also occur in younger women or those without children.

Types of Adenomyosis

There are three main types of adenomyosis:

Focal Adenomyosis

Focal adenomyosis refers to when adenomyosis is limited to one specific area or region of the uterus.

Adenomyoma

Adenomyoma is characterized by the formation of a localized mass or tumor within the uterine muscle.

Diffuse Adenomyosis

Diffuse adenomyosis occurs when it affects the entire uterus or large areas, causing widespread tissue infiltration throughout the myometrium.

How do you know if you have adenomyosis?

The only definitive way to diagnose adenomyosis is through a surgical procedure, such as a hysterectomy or laparoscopic deep excisional adenomyosis surgery (LEAS).

Magnetic resonance imaging (MRI) and transvaginal ultrasonography may be able to provide a non-invasive assessment, but a confirmed diagnosis can only be made through surgery.

Although one in three people with adenomyosis are asymptomatic (do not have symptoms), some common signs and symptoms of adenomyosis include:

• Painful periods with severe cramps
• Heavy menstrual bleeding
• Enlarged and tender uterus
• Pelvic pain and pressure
• Painful intercourse
• Increased bloating or swelling in the lower abdomen
• Infertility or difficulty getting pregnant

Risk Factors for Adenomyosis

People with the following risk factors may be more likely to develop adenomyosis:

• History of endometriosis
• Prior uterine surgeries, such as C-sections or fibroid removal
• Having had multiple pregnancies
• Having a history of ectopic pregnancy (pregnancy outside of the uterus)
• Taking tamoxifen, a medication used for breast cancer treatment

Management and Treatment Options for Adenomyosis

There’s no one-size-fits-all solution for managing and treating adenomyosis, but potential options include:

Medical Management

• Hormonal birth control: Oral contraceptives, intrauterine devices (IUDs), progestins, or GnRH analogs can regulate menstrual periods, lessen bleeding, and potentially shrink adenomyosis
• Over-the-counter pain relievers: NSAIDs like ibuprofen or naproxen can help alleviate pain.

Surgical Management

• Conservative surgery (laparoscopy/laparotomy): Aims to remove localized adenomyosis while preserving the uterus. This approach can benefit younger women with fertility desires. This option may carry a slightly increased risk of uterine rupture during pregnancy.
• Hysteroscopic resection: Suitable for limited adenomyosis but isn’t recommended for women seeking pregnancy due to potential endometrial damage.
• Definitive surgery: The only way to cure adenomyosis is a hysterectomy (removal of the uterus). This should be reserved for patients who have completed childbearing.

Endometriosis vs. Adenomyosis

The main difference between endometriosis and adenomyosis is that endometriosis occurs outside the uterus, whereas adenomyosis involves endometrial tissue growing within the muscular wall of the uterus itself.

This misplaced tissue responds to hormonal changes just like the normal lining, but because it’s embedded deeper, it can’t be shed during menstruation, leading to persistent pain, heavy bleeding, and other symptoms associated with adenomyosis.

The location of the misplaced tissue influences the type of pain experienced.

Endometriosis often causes pelvic pain that can be severe and radiates to other areas like the lower back, thighs, and even the rectum. Pain may worsen during menstruation, ovulation, or bowel movements.

Adenomyosis primarily affects the uterus, leading to symptoms like painful periods, heavy bleeding, and sometimes cramping that can occur throughout the menstrual cycle, not just during periods.

It’s important to note that while endometriosis and adenomyosis are distinct conditions, they often occur together. Studies show a significantly higher prevalence of adenomyosis in women with endometriosis, ranging from 15% to nearly 90%, depending on the diagnostic method.

How do endometriosis and adenomyosis affect fertility?

Both endometriosis and adenomyosis can cause infertility or difficulty getting pregnant.

Endometriosis and Fertility

Infertility is the sixth fundamental symptom of endometriosis.

Here are a few ways endometriosis can affect fertility:

• Inflammation: Inflammation from endometriosis can create molecules (cytokines) that slow down sperm and eggs, making fertilization difficult.
• Scar tissue: Endometriosis can cause scarring and adhesions in the pelvis. This can block fallopian tubes and ovaries, preventing sperm and egg from meeting.
• Hormonal imbalances: Endometriosis may also affect ovulation, preventing eggs from leaving the ovaries.

These issues can make it harder to get pregnant and may increase the risk of miscarriage.

Treatment Options for Endometriosis-Associated Infertility

• Laparoscopy: This minimally invasive surgery is the preferred surgical approach for diagnosis and treatment. It allows for the removal or ablation of endometrial implants and restoration of pelvic anatomy, potentially improving fertility, particularly in cases of minimal-moderate endometriosis. When dealing with endometriomas (cysts containing endometrial tissue), surgical excision offers a higher chance of improving fertility compared to ablation (destruction) of the cyst. However, surgery is often not the first-line treatment to help with fertility issues. Other fertility treatments may actually be more beneficial to help a patient conceive.
• Intrauterine Insemination (IUI): This approach stimulates ovulation to produce one to two eggs, followed by intrauterine insemination (placing sperm directly in the uterus) to increase the chances of fertilization. It can be effective for young women with minimal-moderate endometriosis, particularly after surgical treatment, to address any anatomical distortions.
• In Vitro Fertilization (IVF): IVF is considered the most successful treatment for endometriosis-associated infertility, regardless of the endometriosis Studies suggest similar or even slightly higher success rates in IVF for women with endometriosis compared to other infertility causes. For some patients with endometriosis undergoing IVF, pre-treatment with GnRH agonists may be beneficial in suppressing inflammatory factors and potentially improving IVF outcomes.

Adenomyosis and Fertility

According to one 2021 review published in the International Journal of Environmental Research and Public Health, adenomyosis may increase the risk of miscarriage, premature birth, and early rupture of membranes during pregnancy.

Here are a few ways adenomyosis can affect fertility:

• Uterine abnormalities: The misplaced endometrial tissue can change the shape of the uterus, potentially hindering sperm movement and embryo implantation.
• Muscle issues: Adenomyosis can cause the muscles in the uterus to contract irregularly, which might affect sperm transport and implantation.
• Reduced receptivity: Changes in molecules and genes may make the lining of the uterus (endometrium) less receptive to a fertilized egg.
• Inflammation: Chronic inflammation linked to adenomyosis might harm sperm, implantation, and development of the lining needed for pregnancy.

Treatment Options for Adenomyosis-Associated Infertility

• Conservative surgery: This approach, particularly for well-defined adenomyomas (localized lesions), offers the potential for good fertility outcomes, especially for younger women. It involves excising the adenomyomatous tissue while preserving the uterus. However, there may be a slightly increased risk of uterine rupture during pregnancy.
• High-intensity focused ultrasound (HIFU): This non-invasive method uses focused ultrasound waves to target and ablate adenomyosis While early studies show promise for pain control and potentially improved fertility, more research is needed to confirm its long-term effectiveness. This procedure is not performed at RMA.
• Assisted reproductive technologies (ART): When surgery isn’t suitable or hasn’t yielded success, ART can provide a viable option for women with adenomyosis and infertility. Examples include IUI and IVF.

If you suspect you have endometriosis or adenomyosis, early diagnosis and treatment are essential to improving fertility outcomes. A healthcare professional experienced in women’s health can create a personalized treatment plan to address your needs and improve your quality of life.

RMA Research on Adenomyosis

In 2018, RMA published award-winning research on the link between adenomyosis seen on 3D ultrasound and clinical outcomes following IVF.

Our research showed that only women with obvious adenomyosis on 3D ultrasound are at increased risk for adverse outcomes following frozen embryo transfer. Specifically, the study demonstrates that women with obvious adenomyosis have a higher likelihood of experiencing miscarriage.

Most prior studies regarding adenomyosis focused on outcomes following fresh embryo transfer. With an increasing trend toward frozen embryo transfer, we felt examining outcomes in this patient population was important.

Clinical Outcomes

The study began by evaluating outcomes in patients with adenomyosis compared to those without; no difference was found in clinical outcomes. However, when looking at the 21 patients with obvious adenomyosis, some differences emerged. Specifically, patients with obvious adenomyosis were almost four times as likely to experience a miscarriage compared to those without adenomyosis – those with the condition had a 23.8 percent chance of miscarrying, while those without it had a 6.3 percent chance.

What was probably most interesting, however, is that we did not see a difference in clinical outcomes for patients with more subtle adenomyosis. This suggests that only patients with obvious adenomyosis are at increased risk for adverse outcomes following frozen embryo transfer.

RMA Network: Your Partner in Reproductive Health

Endometriosis and adenomyosis can present challenges on the path to parenthood. RMA Network is a leading provider of advanced reproductive technologies (ART) with a network of clinics nationwide. Our fertility specialists understand the complexities of these conditions and can help you explore all your options, including IUI, IVF, and other assisted reproductive techniques, to achieve your dream of becoming a parent.

Remember: With knowledge and the right support system, you can manage endometriosis or adenomyosis and take control of your reproductive health.