Endometriosis or adenomyosis: making the right diagnosis

When there are two conditions with similar symptoms, they can easily be mistaken. Even experts can encounter difficulties when differentiating between the two. Highly experienced consultant gynaecologist Mr Stephen Quinn goes into a clear but detailed guide between endometriosis and adenomyosis in this article, helping us to understand the difference and how they are each diagnosed.

What is the difference between endometriosis and adenomyosis?

Endometriosis is a condition whereby there is a presence of endometriotic cells (cells from the lining of the womb) that are found in areas outside of the womb, or uterus. This can be around the bladder, around the ovaries, sometimes within the ovaries, sometimes in the structures surrounding the uterus, and sometimes, rarely, even as far up as the diaphragm and far away from the uterus.

Adenomyosis is an invasion of those endometriotic cells within the uterus itself. It’s not extending outside of the womb, but that then causes the uterus to become often enlarged, inflamed, and it increases what we call the junctional zone. The junctional zone is the area between the cells on the inside of the womb and myometrial cells, the muscle fibres of the rest of the uterus.

Endometriosis tends to cause pain, which tends to be the predominant symptoms. Adenomyosis, while it can cause pain, tends to cause more heavy bleeding compared to endometriosis, and of course, also painful periods. The difference between the two conditions is not just the position of the endometrial cells, but also the symptoms, in that adenomyosis is more bleeding pain, and endometriosis is predominantly pelvic pain.

Why are the conditions sometimes confused?

Because both conditions involve the migration of endometriotic cells from their usual location, it can be confusing in terms of the diagnosis. Once again, endometriotic cells found outside of the uterus is endometriosis; those endometriotic cells that have just moved outside the endometrium but still inside the womb is adenomyosis. And because, unfortunately, similar sounding names and some overlap between the symptoms (particularly painful periods), there can be sometimes confusion.

How do doctors differentiate between the two conditions?

This is often done with a combination of clinical findings, the taking of a thorough history from the individual, by examination, and by imaging. The imaging involves ultrasound imaging of the pelvis, and often MRI scan of the pelvis to give us accurate imaging of the uterus, the surrounding structures, whether we think there is presence of deep endometriosis, and whether we believe there is presence of adenomyosis. In addition to endometriosis, adenomyosis can also be confused with fibroids because both conditions can cause heavy painful periods, both conditions can cause enlargement of the uterus, and the treatments are often very similar, also.

Is there a difference in symptoms of endometriosis and adenomyosis?

Endometriosis can characteristically cause pelvic pain. This pain can be:

• worse during the time just before and the first few days of a period
• when opening the bowels, passing stool
• during sexual intercourse
• sometimes when passing urine

Adenomyosis tends to be a condition which is linked more with pain and bleeding, and more frequently, heavy menstrual bleeding. Those periods can be more painful. There is less commonly pain during intercourse, and less commonly pain when opening the bowels.

When should you see a doctor about these symptoms?

If these symptoms are affecting an individual’s quality of life and if these symptoms are not being controlled by simple painkillers (analgesia), such as paracetamol and ibuprofen, then an individual should contact their local doctor for an assessment.

If an individual is worried that, for example heavy bleeding, is having an effect on their quality of life, if they feel that they are becoming symptomatic because of anaemia, if they are feeling dizzy, feeling increased fatigue, we would advise them once again to see their local doctors for an assessment of blood tests. If the individual is experiencing pain that is preventing them from doing activities of normal daily living, if it’s stopping them from going to work, stopping them from exercising, despite simple analgesia, then we would suggest a review by the local doctor. In addition to that, if an individual has a lot of these symptoms and problems conceiving, where it has been longer than 12-months of actively trying to conceive with no successful pregnancies, then again, being seen by a local doctor to whether any of these conditions may be affecting the individual would be sensible.

How is each condition treated?

Each of these conditions are treated with a combination of what we describe as conservative medical non-surgical treatments. Conservative treatments can be simply lifestyle, smoking cessation, controlling weight, improving diet, exercising, etc., and these can have a very positive effect on both conditions.

Medical treatments include simple painkillers, starting off with simple analgesia and sometimes increasing to stronger painkillers if they are required. There are medications in the case of adenomyosis that can reduce bleeding each month, such as Tranexamic acid and Mefenamic acid, which can be very effective in controlling the amount of bleeding the individual experiences each month. After that, we may look at hormonal treatments that can be effective in managing symptoms, treatments such as the progesterone-only pill or the combined-all contraceptive pill. Devices such as the Mirena coil or long-acting reversible progesterone contraceptives can be very effective at managing pain and bleeding from adenomyosis.

Endometriosis can be managed similarly medically, again starting with simple analgesia and then increasing to stronger painkillers as required. In many cases, hormonal treatments, such as the combined-all contraceptive pill taken in a three-monthly manner, can be very effective in reducing pain and bleeding. The progesterone-only pill is extremely good at managing pain from endometriosis, and again the Mirena coil and some of the longer-acting reversible contraceptives can be very effective.

If those options are not effective, then we move on to surgical management. Surgical management of endometriosis will often involve a laparoscopy (keyhole surgery to the abdomen to examine the pelvic organs), and if encountered, treatment of the endometriosis. This can be either by excision, removal of the endometriosis deposits, or by electrodiathermy or in some cases laser treatment. If a collection of endometriosis is found in the ovary, then a cystectomy can be performed, and restoration of normal anatomy is very helpful at treating symptoms.

With adenomyosis, surgical treatment is more difficult because removal of the adenomyosis is sometimes not possible, but there are treatments to the endometrium that can reduce the heaviness of bleeding, such as endometrial ablation. If that’s not successful, we sometimes consider treatments such as uterine artery embolization as a way of managing symptoms of adenomyosis. If fertility is no longer a consideration, in some cases a hysterectomy may be required if the other treatments have not been successful. Likewise for endometriosis, as a last resort, sometimes a hysterectomy with removal of the ovaries, so with hysterectomy may be required if all other treatments have been unsuccessful.

If you are experiencing symptoms of either condition or would like more information, you can schedule a consultation on Mr Quinn’s Top Doctors profile.