SYDNEY, AUSTRALIA – Women undergoing surgery for endometriosis have a high prevalence of sonographic signs of adenomyosis, which has significant implications for fertility treatment and secondary prevention, said the lead author of a new study.
Of 103 women having surgery for endometriosis, 91 (88.4%) showed at least one sonographic sign of adenomyosis, according to data presented at the International Society of Ultrasound in Obstetrics and Gynecology world congress.
An irregular endometrial-myometrial junction was the most common finding (86.3%), followed by myometrial cysts (85.3%), hyperechoic islands (80%), and asymmetrical myometrial thickening (75.6%). Other sonographic signs included parallel shadowing, localized adenomyomas, and linear striations.
Dr. Vered Eisenberg
The presence of sonographic findings of adenomyosis was associated with age, dysmenorrhea, dyspareunia, and infertility.
Adenomyosis has long been associated with endometriosis, but lead author Dr. Vered Eisenberg said she was still surprised by the high prevalence of the sonographic signs of adenomyosis in this population of women.
"We know that they coexist, and I noticed when I was doing the scans that there was a lot of adenomyosis in the women that I was seeing, as opposed to women that I knew did not have endometriosis who had less adenomyosis," said Dr. Eisenberg, senior obstetrician and gynecologist at the Sheba Medical Centre, Tel Hashomer, Israel. She is a specialist in obstetric and gynecologic ultrasound.
The average age of the patients in the study was 34 years, and just over half were nulliparous. Nearly one-third of the patients presented with infertility, and 23% were undergoing in vitro fertilization (IVF).
Dr. Eisenberg said the finding had direct implications for treatment of these women, both for the adenomyosis and fertility problems, with growing awareness that adenomyosis may be independently responsible for fertility problems.
"There are several reviews that have looked into that, suggesting that the structure of the endometrial lining, which is affected by adenomyosis, is hindering the implantation of the embryo; that could be how it affects fertility," Dr. Eisenberg said in an interview.
"If you treat the endometriosis and you send the woman for IVF, for example, you might not manage to get her pregnant because the lining will still be problematic; so if you know that in advance, you may adjust your IVF accordingly," she said.
The coexistence of adenomyosis and endometriosis, as well as the patient’s fertility desires, may influence surgeons’ treatment decisions, Dr. Eisenberg said.
"When you consider operating on a woman [with endometriosis], you would either operate on her for intractable pain or for infertility. If she desires fertility, then you would want to save time, so you would end up doing the surgery much sooner," she said.
However, surgery would not resolve the adenomyosis, which would still require treatment.
In women who are not concerned about fertility, it might instead be possible to delay or avoid an operation altogether, and instead manage both the endometriosis and adenomyosis with treatments such as Mirena, a levonorgestrel-releasing intrauterine system.
Dr. Eisenberg stressed that the findings were sonographic only and were not histologically confirmed, as none of the women underwent a hysterectomy.
No conflicts of interest were declared.