BELIEVE MIDWIFERY SERVICES, LLC

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1 , LLC TITLE: ADENOMYOSIS EFFECTIVE DATE: May, 2012 POLICY STATEMENT Adenomyosis is a common benign gynecologic disorder that any certified nurse-midwife who provides gynecologic care is likely to see on a regular basis in practice. Women with adenomyosis sufferers and the clinicians who care for them often are frustrated with several aspects of this disease: overlap of adenomyosis signs and symptoms with other disorders such as endometriosis and fibroids; lack of clarity about the etiology of adenomyosis; imprecision of available diagnostic modalities; and a scarcity of effective treatment options aside from often-undesired hysterectomy. Fortunately, recent basic science and clinical research have begun to shed some light on this challenging gynecologic condition and have provided new options for treatment. The purpose of this practice guideline is to assist midwives in caring for women by reviewing current understanding of the pathophysiology of adenomyosis, describing clinical presentations of this condition, presenting available diagnostic and treatment methods, and describing the role of the midwife in the management of this condition. BLOOD BORNE PATHOGEN EXPOSURE CATEGORY: I (Involves exposure to blood, body fluids, or tissues) FUNCTION: Care of Clients EQUIPMENT: 1. Assessment equipment - particularly for bimanual exam POINTS OF EMPHASIS: Adenomyosis occurs when endometrial glands and stroma, normally sequestered in the endometrium, invade the myometrium. the smooth muscle in the myometrium often hypertrophies in response to this misplaced tissue, making the uterus enlarged and tender on examination. Adenomyosis is a condition in which the glandular endometrial tissue invades the thick, muscular uterine myometrium and in doing so, stimulates a local inflammatory response that results in hypertrophy and hyperplasia of the surrounding muscle fibers. Adenomyosis is a benign condition that may involve all or part of the uterus. The most common type of adenomyosis, found in approximately two-thirds of cases, is diffuse adenomyosis in which the invading endometrium causes a generalized expansion of the uterine walls, and the adenomyotic foci are distributed relatively evenly through the myometrium. Much less common is focal adenomyotic lesions or nodules within the uterine muscle. The reported prevalence of adenomyosis varies widely, ranging from 1% to 70%, depending on the population studied and the criteria used to diagnose adenomyosis. A recent systematic review of the epidemiologic features of adenomyosis estimated the mean prevalence to be 20% to 30%. Thus, a common condition in gynecologic practice. Adenomyosis is sometimes called endometriosis interna, indicating that the two are variants of the same process because they are sometimes seen together. This is controversial, and others argue that the fact that adenomyosis and endometriosis share a common feature of ectopically located endometrial glands and stroma does not indicate that they share a common cause. Clinicians also may confuse adenomyosis with fibroids because both can cause menorrhagia, pelvic pain and pressure, and uterine enlargement. Moreover, imaging modalities may not be able to differentiate between fibroids and focal adenomyosis. Both fibroids and adenomyosis may exist in the same woman. Fibroids are the most frequently associated other pelvic pathology in women with adenomyosis, found in 35% to 55% of women with adenomyosis. Approximately 80% of women with adenomyosis and dysfunctional uterine bleeding have additional pelvic pathology.

2 PRACTICE GUIDELINE Page 2 of 5 Risk Factors Age appears to be a significant predictor; adenomyosis is most often identified in the fourth or fifth decade of women s lives. The menstrual and reproductive factors most strongly correlated with developing adenomyosis are having been pregnant and having a history of spontaneous abortion or a history of a uterine surgical procedure such as dilation and curettage. Increasing parity predisposes women to developing adenomyosis. However, one study found that nulliparous women had a significantly higher rate of adenomyosis than multiparous women. Women who are obese or who had menarche at age 10 or younger have a greater likelihood of having adenomyosis. Adenomyosis also may be associated with elevated levels of follicle-stimulating hormone and luteinizing hormone as well as a history of depression. Etiology Although the cause of adenomyosis is unknown, evidence suggests that the disease is associated with chronic disruption of the margin between the basal layer of the endometrium and the myometrium, allowing significant invasion of endometrial glands and stroma into the myometrium. This margin between the endometrium and myometrium is different from margins between mucosal and muscular layers elsewhere in the body. There is no submucosal layer, allowing for physiologic and necessary penetration in early pregnancy. Trophoblastic invasion during pregnancy disrupts this margin and allows endometrium to invade myometrium as myometrial fibers change during pregnancy. Other pregnancy-related events such as cesarean birth, sharp curettage, and induced abortion also may contribute to the disruption of the endometrial-myometrial margin by permitting abnormal invasion of endometrial glands and stroma into the myometrium. Moreover, hormonal environments, including the increased exposure to high endogenous levels of estrogen associated with pregnancy, may contribute to the development of adenomyosis. In addition to hormonal factors, a variety of genetic and immunologic factors appear to mediate the development of adenomyosis. The process also may be exacerbated by hyperperistalsis of the uterus of dysfunctional myometrial contractility. There also may be an underlying defect in the myometrium that allows the endometrium to invade the muscle. In many situations, a firm diagnosis of adenomyosis is not possible and may not be necessary for appropriate and successful clinical management. The differential diagnosis, based on typical symptoms, physical examination findings, and imaging results, may include adenomyosis, fibroids, endometriosis, ovarian masses, and endometrial cancer. PROCEDURE: 1. Obtaining a thorough and accurate history can provide initial clues to identifying adenomyosis, but significant challenges remain for clinicians. There is no single symptom or constellation of symptoms that is pathognomonic of adenomyosis.

3 PRACTICE GUIDELINE Page 3 of 5 a. The most common symptoms are menorrhagia, reported by 23% to 82% of symptomatic women, and dysmenorrhea, reported by 30% to 50% of symptomatic women. Women also report metrorrhagia, pelvic pain, dyspareunia, and infertility. 2. On physical examination, women with adenomyosis often have diffusely tender uteri. This disease may cause uterine enlargement, although it is unusual for an adenomyotic uterus to be larger than the size at 12 week s gestation. Ultrasound 3. The ability to diagnose adenomyosis is influenced by the skill and experience of the sonographer and the sonographic criteria used. Common ultrasound findings in women with adenomyosis include uterine enlargement, an irregular myometrium with poorly defined cystic areas and striations, and an ill-defined endometrial-myometrial border. a. Transvaginal ultrasound is more useful than transabdominal ultrasound because the limited resolution of the abdominal approach causes difficulties in distinguishing focal adenomyosis from fibroids and appreciating other subtle features of adenomyosis. However, one advantage of transabdominal imaging distance of the transvaginal approach may miss distal portions of a large uterus. b. A recent review of 23 studies that examined the sensitivity and specificity of ultrasound in diagnosing adenomyosis yielded a pooled sensitivity of 72% and specificity of 81%. MRI 4. Magnetic resonance imaging has several advantages in the diagnosis of adenomyosis including its noninvasiveness, reproducibility, outstanding resolution in soft tissue contrast, full field of view, lack of operator dependence, and absence of ionizing radiation. Drawbacks to the use of the MRI include its expense and lack of availability. Another challenge is that researchers have not agreed on precise diagnostic criteria. Although the diagnosis of adenomyosis is based on the presence of a thickened myometrial junctional zone, the definition of thickened myometrial junction zone varies - it may be from 5 mm to 12 mm or greater than 12mm. The sensitivty of MRI varies from 46% to 89%, and specificity varies from 65% to 98%. CT Scan 5. Although evidence is limited, CT seems to have little usefulness in accurate diagnoses of adenomyosis because of its ability to allow precise differentiation between adenomyosis, normal myometrium, and fibroids. Nonimaging diagnostic modalities 6. These methods include laboratory testing, biopsies, and laparoscopy. Unfortunately, none of these have shown much promise. Developing a Treatment Plan 7. It is often difficult to make a firm adenomyosis diagnosis, and there is little risk in treating based on type and severity of symptoms. Thus, after ruling out other, more serious conditions such as endometrial cancer, it is appropriate to offer women several options, based on either a definitive of presumed adenomyosis diagnosis. 8. For some women, particularly those who are close to menopause, expectant management is appropriate while awaiting the cessation of menses and troublesome symptoms. 9. Other women, especially those who are comfortable irreversibly ending their fertility and those who are not opposed to surgery, desire hysterectomy, which is the definitive treatment for adnomyosis. 10. For women who want therapy but not surgery, there are a number of medical treatment options that allow individualization of care for women with adenomyosis. a. Oral Hormonal Treatments including COC, various progesterone only, and gonadotropin-releasing hormone agonists. b. COCs effectively treat menorrhagia and dysmenorrhea by maintaining a thinner endometrium, which decreases inflammation by blocking cyclooxygenase (Cox-2) expression. However, a recent review concluded that the evidence is mixed, and some anecdotal reports suggest that combined oral contraceptives may actually stimulate adenomyotic foci in undesireable ways. Thus, the

4 PRACTICE GUIDELINE Page 4 of 5 response to COC should be monitored carefully. When used, the recommended treatment is a monophasic regimen. c. Progestogen-only oral therapies such as dydrogesterone and 19-nortestosterone derivatives like desogestrel have been used extensively to effectively treat ectopically located endometrium in endometriosis for decades. However, the use of progestogens to treat adenomyosis has not been studied extensively. d. Gonadotripin-releasing hormone agonists such as leuprolide have been used extensively for treatments for adenomyosis. These medications worth through the suppression of estrogen, shrinking adenomyotic areas, and causing a state of reversible, medically induced menopause. Numerous studies have demonstrated these effective, and some users have been successful in achieving pregnancy after discontinuation. Although these medications provide effective symptom control during treatment, symptoms often quickly return after medication discontinuation. Additionally, the use of these medications is limited by their side effect profile of hot flashes, vulvovaginal atrophy, mood changes, and diminished bone density. Consequently, gonadotropinreleasing hormone agonists are typically used only for short periods of time, usually no more than 6 months. Some investigators propose that the best uses of gonadotropin-releasing hormone agonists are to assist women who want to achieve pregnancy or to shrink adenomyotic nodules prior to excision. 11. Nonhormonal medications used to treat menorrhagia and dysmenorrhea including long-standing therapies such as NSAIDS as well as newer therapies such as tranexamic acid (Lysteda) and valproic acid. a. NSAIDS are superior to placebo, but are less effective than the Mirena. 12. Tranexamic acid provides an important option for treating menorrhagia in women who prefer to avoid hormones or who are not candidates for hormonal treatments. The US FDA only approved its use in 2009, although it has been used extensively in other countries to treat menorrhagia. It is currently marketed under the brand name of Lysteda, with a recommended dosage of 1300 mg 3 times daily. Therapy should be started with menstruation and continued for a maximum of 5 days with each cycle. a. Tranexamic acid works by inhibiting plasminogen. Women with menorrhagia have an increased level of tissue plasminogen activator, enzymes that dissolve clots. This diminished ability to form clots contributes to heavy uterine bleeding with menses. Tranexamic acid, as an antifibrinolytic, allows normal endometrial clotting and reduces heavy menstrual bleeding by competitively blocking the conversion of plasminogen to plasmin. b. Contraindicated in women with a history of venous thromboembolism, and the US FDA strongly cautions against combining hormonal contraception with tranexamic acid. c. Possible side effects include headache, sinus and nasal discomfort, back pain, nausea, vomiting, diarrhea, disturbance in color vision, musculoskeletal pain, and fatigue. However, no difference was found with placebo. 13. Valproic acid, long history of treatment for epilepsy and bipolar, is another potential treatment for adenomyosis symptoms. Women tolerated this well in a single pilot study, had complete resolution of dysmenorrhea, and experienced reduced uterine size. 14. The Mirena, by far, the most promising therapy for non-surgical management of adenomyosis. This therapy has been used for more than a decade for adenomyosis and studies have demonstrated improvement in menorrhagia. It also decreases dysmenorrhea and uterine volume. Significant improvements are seen beginning 2 to 3 months after LNG-IUS insertion, and most women report relief from dysmenorrhea within 6 months. 15. Although midwives usually are not involved with surgical approaches to adenomyosis, it is helpful to some to have an understanding of the other options that women may consider on consultation with a gynecologist. The decision to use a surgical approach to treatment is based on factors such as the woman s age; future fertility desires; the seize, site and extent of the adenomyostic lesions; and the surgeon s preferences and skill. Options include hysterectomy, uterine artery embolization, excision of focal adenomyotic lesions, and endometrial ablation. REFERENCES: Cockerham, A.Z. (2012). Adenomyosis: a challenge in clinical gynecology. Journal of Midwifery & women s health, 57(3),

5 PRACTICE GUIDELINE Page 5 of 5 Originated: May, 2012 Penny Lane MSN, CNM DATE: 5/27/2012 Anastasia Glassburn DATE: 5/29/2012