Adenomyosis is a common gynecologic condition where the tissue that normally lines the inside of the uterus grows directly into the muscular wall (myometrium). This misplaced tissue functions normally, thickening and bleeding during the menstrual cycle, which leads to the thickening and enlargement of the entire uterus. When adenomyosis causes persistent symptoms that do not respond to medication, surgery becomes a primary consideration. Laparoscopy is the preferred minimally invasive technique, offering benefits like smaller incisions and reduced recovery time.
What Is Adenomyosis and Why Surgery Is Considered
The presence of this displaced tissue within the uterine muscle results in severe symptoms. These include heavy or prolonged menstrual bleeding (menorrhagia) and severe menstrual cramping and pelvic pain (dysmenorrhea). The uterus may also become enlarged, causing feelings of bloating or pelvic pressure.
Diagnosis often begins with a transvaginal ultrasound, but Magnetic Resonance Imaging (MRI) is the most effective non-invasive method for visualizing the extent of the disease. Surgery is necessary when medical management fails to control symptoms. It is also recommended when the severity of the pain or bleeding significantly impairs daily function or when the uterine enlargement is substantial.
The decision to proceed with surgery is connected to a patient’s desire for future fertility. For those who have completed childbearing, surgery offers a definitive solution to chronic pain and bleeding. Conversely, for patients who wish to preserve their ability to conceive, the surgical approach must be carefully selected to remove the diseased tissue while maintaining the integrity of the uterus.
Laparoscopic Techniques for Treatment
Laparoscopy is the preferred approach for operating on the uterus, utilizing small incisions and specialized instruments. This technique is applied in two main ways for adenomyosis, each with a distinct goal regarding uterine preservation. The choice hinges on whether the patient seeks a permanent cure or prioritizes maintaining fertility.
Laparoscopic Hysterectomy
A laparoscopic hysterectomy is the definitive treatment for adenomyosis, involving the complete removal of the uterus. Because the source of the disease is removed, this procedure guarantees the cessation of adenomyosis-related symptoms, offering a permanent resolution for patients who do not desire future pregnancies. The laparoscopic method results in less blood loss and a reduced risk of infection.
The procedure involves the surgeon making a few small incisions, typically less than a centimeter each, through which a camera and surgical tools are inserted. Despite the potential for the adenomyotic uterus to be significantly enlarged and highly vascular, laparoscopic techniques allow for its careful removal, often vaginally or through morcellation. The surgeon must possess advanced skill to navigate the distorted anatomy and manage the increased blood supply.
Laparoscopic Adenomyomectomy
For patients who wish to retain their fertility, laparoscopic adenomyomectomy is the uterus-sparing option. This procedure involves surgically excising the adenomyotic tissue while leaving the healthy portion of the myometrium intact. The feasibility of this procedure is highest when the adenomyosis is focal, meaning it is concentrated in a distinct mass or nodule, rather than being diffuse throughout the uterine muscle.
The technical difficulty of this surgery is significantly higher than a hysterectomy because there is no clear boundary between the abnormal and healthy muscle tissue, making complete removal challenging. To minimize blood loss during the excision, specialized techniques may be employed, such as the temporary clamping or injection of medication to constrict the uterine arteries. After the diseased tissue is removed, the remaining uterine muscle must be meticulously reconstructed with multiple layers of sutures to ensure the structural integrity of the organ, which is crucial for any subsequent pregnancy.
Recovery Expectations and Surgical Outcomes
The minimally invasive nature of laparoscopic surgery results in a smoother post-operative course. Following a laparoscopic hysterectomy, the typical hospital stay is relatively short, often just one to two days. Patients are encouraged to begin gentle movement soon after the procedure to aid circulation and reduce the risk of blood clots.
Immediate discomfort is managed with prescribed oral pain medication, though many patients report a unique pain sensation in the shoulder or chest. This referred pain is a temporary side effect caused by the carbon dioxide gas used to inflate the abdomen during the laparoscopic procedure, which irritates the diaphragm. The general timeline for a return to light daily activities is often within one to two weeks, with a full physical recovery, including the lifting of heavy objects and strenuous exercise, generally requiring four to six weeks.
The long-term outcome following a laparoscopic hysterectomy is a definitive cure, with a near 100% success rate for eliminating adenomyosis-related symptoms. The outcomes are different for the fertility-sparing adenomyomectomy, which aims for symptom improvement rather than a permanent cure. Studies show that this conservative surgery can be highly effective, with reports of up to 93% of patients experiencing significant relief from dysmenorrhea and approximately 77% seeing improvement in heavy bleeding within months of the procedure.
However, the nature of adenomyosis means that the risk of the disease recurring remains a concern after an adenomyomectomy. Recurrence rates vary depending on the extent of the original disease and the surgical technique used, but symptom relapse can occur in the range of 10% to 20% over a few years of follow-up. Despite this, the procedure successfully preserves the uterus and allows patients to pursue pregnancy, though the risk of uterine rupture during a future labor must be discussed due to the surgical scarring and uterine reconstruction.
Non-Surgical and Alternative Management
Medical management is the initial course of action, utilizing hormonal therapies that target the tissue’s reliance on estrogen. First-line treatments include the Levonorgestrel-releasing Intrauterine System (LNG-IUS), which releases progestin directly into the uterus to reduce heavy bleeding and pain. Other hormonal options are combined oral contraceptives and Gonadotropin-Releasing Hormone (GnRH) agonists, which temporarily suppress hormone levels to shrink the adenomyotic tissue.
When medical options fail, interventional radiology procedures offer uterus-preserving alternatives. Uterine Artery Embolization (UAE) is a minimally invasive treatment where tiny particles are injected into the blood vessels supplying the uterus to cut off blood flow to the adenomyotic tissue, causing it to shrink. UAE has demonstrated effectiveness in relieving symptoms for over 80% of patients and is performed on an outpatient basis with minimal downtime.
Another non-surgical approach is High-Intensity Focused Ultrasound (HIFU), which uses highly concentrated sound waves to generate heat and destroy the abnormal tissue without incisions. For cases where laparoscopy is complicated, traditional open abdominal surgery (laparotomy) may still be necessary. These alternatives provide options for symptom control, especially for those prioritizing uterine preservation or avoiding a major surgical operation.