Adenomyosis, often referred to as “endometriosis interna”, is a complex gynecological condition that shares many similarities with endometriosis external. Both conditions lead to debilitating symptoms such as heavy and prolonged menstrual bleeding, severe cramps (dysmenorrhea), chronic pelvic pain, painful intercourse (dyspareunia), and, in many cases, infertility. These symptoms can have a significant impact on women’s quality of life, making timely diagnosis and appropriate treatment essential.

According to Dr. Sanjay Patel, endometriosis surgeon at Mayflower Women’s Hospital, Ahmedabad, co-occurrence of adenomyosis with endometriosis is not uncommon, and it is important to understand the complex nature of both conditions for effective treatment. “Adenomyosis can increase the likelihood of external endometriosis, and both conditions contribute to overlapping symptoms,” says Dr. Patel. “This makes it important for physicians to distinguish between the two and develop tailored treatment plans.”

Challenge of Diagnosing Adenomyosis

Dr. Patel has faced many challenges in diagnosing adenomyosis since the mid-90s. One of the biggest hurdles has been determining the severity of the disease. Adenomyosis presents itself in two forms: focal (localized) tissue growth and diffuse disease, which spreads into the myometrium, the muscular wall of the uterus. This dual presentation complicates diagnosis, as simply estimating the size of the focal enhancement does not provide a complete picture of disease impact.

Historically, physicians estimated the size of the uterus based on weeks of pregnancy to assess the severity of adenomyosis. However, Dr. Patel said this method provides only a partial understanding of the condition. “It became clear that we needed a standardized classification system that took into account both the size of the focal growth and the extent of disseminated disease,” he explained.

Diagnostic and Imaging Techniques

Diagnosis of adenomyosis usually begins with transvaginal ultrasonography. This imaging method can reveal characteristic features such as posterior thickening of the myometrium, myometrial cysts, and linear streaks extending from the endometrium. Additionally, loss of a clearly defined endometrial border and increased vascularity in the affected area can also be seen using color Doppler imaging, which highlights the margins of the adenoma.

For a more detailed evaluation, Dr. Patel often recommends an MRI, which provides a clearer picture of disease progression. MRI scans can detect focal masses, cystic formations, and disease spread to other parts of the pelvis. This advanced imaging helps physicians understand the full extent of the disease and tailor their treatment plans accordingly.

A new classification of adenomyosis

To provide clarity to surgeons and help choose the appropriate treatment path, Dr. Patel developed a standardized classification system for adenomyosis. This classification divides the condition into five stages depending on the size of the focal mass and the extent of spread of the disease.

1. Grade IA: Small, localized lesions up to 3 cm. This is the mildest form of adenomyosis with minimal spread.

2. Grade IB: Disseminated disease spreads to both the posterior and anterior parts of the uterus, accompanied by small local lesions.

3. Grade IIA: Large focal masses (greater than 3 cm), often associated with spread disease or additional small focal growths in other areas of the uterus.

4. Grade IIB: Spread disease affects 50 percent of the uterus. The extent of spread plays an important role in determining treatment strategy.

5. Grade III: This spreading disease has taken the entire uterus under its control. At this advanced stage, the tissue becomes densely vascularized and becomes challenging to image, complicating surgical planning.

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