Women's Health

Treating a common but overlooked source of severe period pain can limit hysterectomies

If you don’t want a hysterectomy, there are several effective treatment options to eliminate severe menstrual cramps.

Up to 90% of women experience painful menstruation. It’s so common that most women just accept pain, cramping, and heavy bleeding as normal symptoms. Many even schedule their lives around their period.

But period pain doesn’t have to be normalized or tolerated. These symptoms might be a sign of a common but abnormal condition called adenomyosis – when endometrial tissue, similar to what lines the inner uterine lining, grows into and enlarges the muscular wall of the uterus.

We don’t know what causes adenomyosis, but we can identify symptoms:

  • Heavy bleeding during periods
  • Bleeding outside of periods
  • Pain during periods and sex
  • Constant pelvic pressure and feelings of bulkiness and tenderness

Adenomyosis, which affects approximately 1 in 3 women, is often misdiagnosed as endometriosis or uterine fibroids because the symptoms can be similar.

We typically see adenomyosis in patients in their 30s and 40s – not because that’s when they start to experience symptoms but because that’s when their symptoms have become unbearable. They can’t work because they’re constantly bleeding through multiple menstrual products, and they’re fatigued because heavy blood loss has resulted in an iron deficiency.

Of those patients who are properly diagnosed with adenomyosis, many are told a hysterectomy is the only treatment option – but that’s not accurate. While hysterectomy can indeed cure adenomyosis, several less invasive and less permanent options are available.

I recently published a review demonstrating that adenomyosis is more common – and treatable – than generally appreciated. Without a proper diagnosis and treatment plan, symptoms will persist. A better understanding of adenomyosis can help more patients and providers distinguish it from other conditions.

I call adenomyosis the mean cousin of endometriosis: You find them hanging out together a lot and many people mix them up, but they're not the same. Patients can have one or both conditions, and we can tailor appropriate treatments to each patient’s symptoms.

Endometriosis and adenomyosis: What’s the difference?

Adenomyosis can be challenging to detect because it shares symptoms and often coexists with other common gynecologic conditions. However, a few key differences set adenomyosis apart from lookalike conditions such as endometriosis.

For starters, endometriosis, which occurs when tissue similar to the endometrium that grows inside the uterus starts growing in places outside the uterus, causes distinct symptoms that adenomyosis doesn’t, such as nerve pain and gastrointestinal issues. Another major misconception is that endometriosis, which affects the outside of the uterus, causes heavy bleeding. But menstrual bleeding occurs when the uterus lining sheds, so excessive bleeding is caused by a condition inside the uterus, such as adenomyosis.

Specialized ultrasound and MRI imaging can detect abnormal uterine tissue growth throughout the pelvis to help diagnose endometriosis – but not always. Adenomyosis is also suspected with imaging. We look for abnormalities in the uterus that are specific to the condition, such as enlargement or asymmetry, and irregular clusters of uterine glands and tissue in the muscular wall. A pelvic exam also can help us find signs of an enlarged or tender uterus.

MRI helps detect uterine adenomyosis by making it possible to see enlargement or asymmetry in the uterus and irregular clusters of uterine glands and tissue in the muscular wall.

Treating adenomyosis: You have options

As common as it is, we still don’t have any FDA-approved treatments specifically for adenomyosis. But treatments for other conditions can be effective. I recommend starting with medical therapy such as:

  • Levonorgestrel-releasing intrauterine system, an intrauterine device (IUD) that releases hormonal medication and provides contraceptive benefits. It has been shown to be the most effective first-line adenomyosis treatment, helping two-thirds of patients avoid hysterectomy.
  • Oral progestin is an estrogen-free birth control pill that can help reduce menstrual pain and bleeding.
  • Combined oral contraceptive pills, which contain both estrogen and progestin, can help with pain and bleeding.
  • Nonsteroidal anti-inflammatory drugs, when dosed correctly, can sometimes help with bleeding as well as pain relief.

If these cause negative side effects or don’t relieve symptoms, oral gonadotropin-releasing hormone agonists and antagonists approved for fibroid and endometriosis-related symptoms might be effective. They slow the growth of uterine tissue by suppressing estrogen. Less tissue means less bleeding, but these medications can only be used for short periods and may have undesired side effects

Depending on your fertility goals, several procedures can reduce symptoms if medical therapy doesn’t help. If you do not wish to become pregnant in the future, treatment options include:

  • Endometrial ablation, a nonsurgical procedure that removes a thin layer within the uterus lining to reduce bleeding
  • Uterine artery embolization, a nonsurgical procedure that blocks blood flow to the uterine tissue masses or fibroids that have developed in the wall of the uterus
  • Hysterectomy, surgery that removes the uterus

Uterine artery embolization is the most well-studied non-hysterectomy treatment for adenomyosis and effectively decreases pain and heavy bleeding. However, 25% of patients who receive this procedure eventually have a hysterectomy because of persistent symptoms.

If you do wish to become pregnant, we might recommend a newer, less common procedure:

  • Adenomyomectomy, a surgery that removes the abnormal uterine tissue
  • Hysteroscopic excision, a minimally invasive surgery that removes tissue growth through a small tube entered through the vagina
  • Uterine wedge resection, a laparoscopic procedure to remove the enlarged section of the uterus

Procedures still under investigation for adenomyosis but showing promise as newer alternatives in other countries include:

  • High-intensity focused ultrasonography, which uses targeted ultrasound energy to destroy the abnormal tissue
  • Radiofrequency ablation, which uses heat to shrink abnormal tissue or fibroids

Related reading: Fertility-sparing treatment for endometriosis and fibroids

We’re still in the early stages of researching adenomyosis-specific treatments, but the more data we gather and awareness we raise, the more patients we can help. Untreated adenomyosis can lead to infertility as well as long-term health issues such as anemia, chronic pain, and mood disorders that develop from cyclical stress, anxiety, and depression that accompany painful, heavy periods.

When to seek treatment for period pain

Menstrual bleeding varies for everyone. But it is not normal to regularly overflow your menstrual products, have to wear a tampon and a pad simultaneously, sleep on a towel overnight, or skip social events simply because you’re menstruating.

If a loved one or provider tells you your pain and discomfort are normal, remember that normal doesn’t mean acceptable. Your life shouldn’t revolve around your period.

If you regularly experience cramps, pain, and abnormal bleeding, talk with your primary care provider – and advocate for yourself if you don’t feel heard. You can also self-refer to any provider within the UT Southwestern Obstetrics and Gynecology department.

To visit with an Ob/Gyn about painful, heavy periods, call 214-645-8300 or request an appointment online.

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