Frederick R. Jelovsek MD
"I am 46 and every month before I start my period, I have really painful cramps. They are so painful that I can barely function. What could be the cause of this?" Carolyn
The new occurrence of cyclic menstrual pain in the decade of the 40's could be due to endometriosis, uterine fibroids, partial cervical stenosis or adenomyosis. By far the most likely cause of these painful menstrual cramps at this time is adenomyosis. This is sometimes called endometriosis interna or internal endometriosis.
Since this is the most likely problem that your doctor will want to rule in or rule out with diagnositic tests, let us focus on adenomyosis. What is adenomyosis?
Adenomyosis is defined as the presence of endometrial glands and supporting tissues in the muscle of the uterus where it normally would not occur. When that gland tissue undergoes growth during the menstrual cycle and then subsequent sloughing, the old tissue and blood cannot get out of the muscle and flow out of the cervix as part of normal menses. This trapping of the blood and tissue causes uterine pain in the form of menstrual cramps. It also produces abnormal uterine bleeding as some of the blood finally escapes the muscle and results in prolonged spotting. For a picture of what adenomyosis schematically looks like, see the (images) at one gynecologist's site.
Adenomyosis occurs more often in the decade of the 40's, perimenopausally. In hysterectomy specimens, adenomyosis can be found from 15% to 25% of the time (1, 2). The glandular change of the endometrial cells in adenomyosis are often incomplete in the second half of the menstrual cycle (luteal phase) and as a result, adenomyosis may not be very responsive to suppression by progesterone. About 50% of adenomyosis is asymptomatic although as it goes deeper into the uterine muscle it tends to be more likely to produce symptoms (3, 4). It is also often associated with fibroids (5 and often associated with other conditions such as ovarian cysts, prolapse and even gynecological cancers (6) that can cause pelvic pain. How is adenomyosis diagnosed?
Up until recent years it was said that adenomyosis was only diagnosable by the pathologist looking at a hysterectomy specimen. Now magnetic resonance imaging (MRI) can more accurately diagnose adenomyosis although many physicians feel this is too expensive a test to use routinely. Patterns of adenomyosis as recognized by MRI seem to either be diffusely spread throughout the uterus (about 66%) or focal lesions (33%) that only occur in one or two places (7). If a non hysterectomy treatment is being considered for adenomyosis, then MRI should be used for the diagnosis and if focal disease were shown, then surgical resection of the endometriosis without doing a hysterectomy could be considered.
Ultrasound especially using color flow doppler can also be used to diagnose adenomyosis (8) . Sometimes it has difficulty differentiating smaller fibroids (leiomyomas) from adenomyosis but it is able to pick up about 80% of the existing lesions. For an in depth discussion on pre surgical ultrasound imaging and diagnosis of adenomyosis, see (The Presurgical Diagnosis of Diffuse Adenomyosis by Helen Bickerstaff, MB, BChir.