Adenomyosis

Disease Description (Causes and Symptoms)

• Definition summary: Uterine leiomyoma (uterine fibroids) is the most common benign tumor originating from the smooth muscle cells of the uterus and is a hormone-dependent lesion influenced by sex hormones such as estrogen. It is common in women of reproductive age (approximately 25–35%), with a particularly higher incidence in those aged 35 and older (approximately 40–50%).
• Causes/pathophysiology: The exact cause is unknown, but proliferation of smooth muscle cells and accumulation of stromal components are key mechanisms. Hormones (estrogen/progesterone), genetic factors, and growth factors are involved in growth.
• Main symptoms: Many cases are asymptomatic (more than half of all cases), but when symptoms are present, they vary depending on the location, size, and number
  • Heavy menstrual bleeding (excessive bleeding), irregular vaginal bleeding
  • Dysmenorrhea, pelvic pain/pressure, abdominal bloating
  • Frequent urination, difficulty defecating, lower back pain, dyspareunia
  • Infertility or pregnancy complications (preterm birth, miscarriage, abnormal fetal presentation, etc.)
  • May often cause anemia (iron deficiency)
• Diagnostic points: May be palpable on pelvic examination, and ultrasound (transvaginal and transabdominal) is the first-line test. If the diagnosis is unclear or for surgical planning, additional evaluation with MRI may be performed. CT may be used as an adjunct.

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Treatment Methods

• Principles for treatment decisions: Individualized based on the presence or absence of symptoms, severity of bleeding/anemia, size·location·number of fibroids, desire to preserve fertility, age, and other factors.

• Medication treatment

  • Symptomatic treatment: Nonsteroidal anti-inflammatory drugs (NSAIDs) — pain relief (limited effect on reducing menstrual volume itself)
  • Bleeding control: Oral contraceptives, progestin preparations, high-dose progestins, or LNG-IUS (levonorgestrel intrauterine system) — effective in reducing menstrual volume
  • Hormonal regulation: GnRH agonists (agonists/antagonists) — used short-term before surgery to reduce uterine and fibroid size (may cause menopausal symptoms). Recently, oral GnRH antagonists (e.g., relugolix combination products) have been used as clinical options.
  • Selective progesterone receptor modulators (SPRMs, e.g., ulipristal): May reduce fibroid size and bleeding in some situations, but availability and monitoring differ by country due to safety issues such as hepatotoxicity.

• Procedural/surgical treatment

  • Myomectomy: Standard surgery for those wishing to preserve fertility (the approach—open, laparoscopic, or hysteroscopic—is determined based on location and size)
  • Hysterectomy: Definitive treatment, with no recurrence (destroys fertility). Selected when symptoms are severe and fertility preservation is not needed.
  • Uterine artery embolization (UAE): Embolization of the uterine arteries to reduce fibroid size for the purpose of relieving bleeding and symptoms. It is conservative, but should be considered carefully because it may affect fertility.
  • MRI-guided focused ultrasound (MRgFUS): May be used as a noninvasive treatment in selected patients.
  • Endometrial ablation: Primarily intended to reduce bleeding. Its use is limited by fibroid size and location, and it may destroy fertility.

• Lifestyle management and precautions

  • Anemia management: Iron supplementation or blood transfusion may be necessary in cases of iron deficiency due to severe heavy menstrual bleeding.
  • Regular follow-up: Small asymptomatic fibroids may be observed (with periodic ultrasound). Reassessment is needed if there are changes in size or worsening symptoms.
  • When planning pregnancy: Because the location of the fibroid (such as a submucosal fibroid close to the endometrium) can affect fertilization, implantation, and miscarriage risk, discuss the treatment plan with a specialist.
  • Concerning findings: If there is postmenopausal occurrence or sudden rapid enlargement, or persistent pain, additional testing is recommended while considering the possibility of malignancy (leiomyosarcoma).

• Risk of complications

  • Chronic anemia; urinary or bowel problems due to pressure on the urinary tract or large intestine; pain; infertility or pregnancy complications
  • Rarely, acute pain due to necrosis (degeneration), and very rarely malignant transformation (leiomyosarcoma; estimated frequency is very low)

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Checklist Before an Outpatient Visit (Including Example Questions)

• Items/materials to prepare or bring
  • List of medications currently being taken (including hormonal medications)
  • Previous test results (pelvic ultrasound, MRI, etc.) and reports (image files if possible)
  • Menstrual history (past 3–6 months): first day of menstruation, duration, menstrual volume (such as the number of pads used)
  • Record of pain and symptoms (pain intensity, frequency, urinary and bowel symptoms, pregnancy history, etc.)
  • Previous surgical history, pregnancy and childbirth history, family history (uterine fibroids or similar diseases)
  • Recent blood test results (CBC, etc.), if available
• Key information to report to the doctor during the visit
  • Whether the bleeding is heavy (whether it interferes with daily life), dizziness and fatigue (symptoms of anemia)
  • Whether pregnancy is desired
  • When the symptoms began and how they have changed (whether there has been sudden worsening)
• Example questions (sentences the patient can use during an outpatient visit)
  • "I have objectively recorded how much my menstrual volume has increased recently. Could you explain what condition I am in compared with the test results?"
  • "I am planning to become pregnant. How will the current treatment affect pregnancy?"

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Examples of General Questions to Ask the Doctor

• "Considering the size and location of my fibroid, what treatment options are recommended?"
• "How likely are my symptoms to improve with medication, and how long is the expected treatment period? What are the side effects?"
• "What is the recovery period and risk of complications for surgery (myomectomy/hysterectomy)?"
• "How likely are the fibroids to recur after treatment, and what options are available if they recur?"

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Examples of Disease-Specific Questions

• "Depending on the location of my fibroid (e.g., submucosal, intramural, or subserosal), how do my chances of achieving pregnancy or my risk of miscarriage differ?"
• "If I want to preserve my fertility, which is more recommended between myomectomy and uterine artery embolization, and what are the advantages and disadvantages of each?"