Endometriosis vs. Adenomyosis

Endometriosis and adenomyosis are both gynecological disorders involving the inner lining of the uterus (the endometrium) growing somewhere other than its normal location. The symptoms of both conditions usually overlap, and they often develop together.

However, endometriosis and adenomyosis are not the same conditions. Different approaches are necessary to both diagnose and treat them.

In endometriosis, the cells lining the inside of the uterus (endometrial cells) grow outside the uterus. This often occurs in the pelvic cavity, fallopian tubes, bladder, or bowels.

In adenomyosis, however, endometrial cells grow deep into the uterus’s muscles but not past them.

In both cases, the endometrial tissue responds to female hormones by thickening and shedding with each cycle. However, it cannot leave the body like normal endometrium, thus causing severe pain and, in some cases, subfertility or infertility.

Symptoms of endometriosis vs adenomyosis

Common symptoms of both conditions include:

• painful periods and cramps (dysmenorrhea)
• Heavy menstrual bleeding with clots (menorrhagia)
• pain during intercourse (dyspareunia)
• painful bowel movements
• numbness and pain in nerves (neuropathy)
• abdominal pain
• painful urination (dysuria)

The symptoms of endometriosis can persist throughout the monthly cycle and may even continue after menopause.

Symptoms of adenomyosis, on the other hand, usually only occur during menstrual periods. Due to the internal growth of endometrial tissue, the uterus in adenomyosis is often thick and large, which can affect the implantation of pregnancy. Symptoms of adenomyosis usually resolve after menopause. It is also possible that women with adenomyosis have no symptoms at all. 

Diagnosis of endometriosis vs adenomyosis

Noninvasive imaging techniques, such as magnetic resonance imaging (MRI) and ultrasonography, may help diagnose endometriosis and adenomyosis.

However, to reach a definite diagnosis of endometriosis, the gold standard approach is laparoscopic excision surgery and a biopsy during surgery.

In adenomyosis, only a biopsy of the uterus can diagnose the disease. However, this typically requires the complete surgical removal of the uterus (hysterectomy).  

Risk factors of endometriosis vs adenomyosis

Endometriosis risk factors include a family history of the disease, early onset of menstruation (before age 11), short monthly cycles (of less than 27 days), and heavy periods lasting more than seven days.

For adenomyosis, risk factors include multiparity (history of multiple births), history of C-sections, history of dilatation and curettage (D&C), smoking, irregular menstrual cycles, and other gynecological conditions such as uterine fibroids and endometriosis. 

How do both conditions affect fertility?

The exact relationship between endometriosis and fertility is not fully clear. Endometriosis may make becoming pregnant difficult, depending on the stage of the disease. However, research shows that 60-70% of endometriosis patients can get pregnant naturally. Some complications associated with the disease, such as a distorted pelvic anatomy, an altered immune system, and low egg quality, may lead to infertility in 30-50% of women with the disease.

It is not fully clear whether adenomyosis can lead to infertility. However, research has shown that the condition leads to a 50% increased risk of miscarriage, almost a 25% risk of premature delivery, and up to a 12% risk of delayed fetal development.

Treatment

There is currently no cure for either endometriosis or adenomyosis, and the only cure for adenomyosis is the removal of the uterus. However, doctors can manage both conditions using surgical and non-surgical approaches, depending on the severity of symptoms.

In case of endometriosis, laparoscopic deep excision surgery is the gold standard of treatment to remove endometrial lesions.

In the case of adenomyosis, the only way to treat the disease entirely is hysterectomy. However, this should only be the last resort. For example, laparoscopic deep excisional adenomyosis surgery can be performed to prevent the uterus from being removed and facilitate future pregnancies. A surgical technique called the Osada procedure can also be performed. Here, the uterine wall is reconstructed after adenomyotic tissues are excised. This technique can reduce symptoms of dysmenorrhea, and patients can go back to normal menstruation and deliver healthy babies.

Medical treatments exist as well that can help with symptoms, but may not reverse the disease or slow the progression of the disease in every patient. The first-line medical treatments are hormonal, either progesterone-only-based medication (pills or hormonal IUD) or combined hormonal medication (both estrogen and progesterone). In some instances, gonadotropin-releasing hormone (GnRH) agonists or antagonists may be used as well.

For both endometriosis and adenomyosis, treatments should be tailored to each patient based on what they have tried in the past, their symptoms, and their goals in family planning.