Adenomyosis: An overlooked suspect for heavy painful periods

Adenomyosis (pronounced as aden-no my-osis) is the BAD cousin of endometriosis. It is an under-recognised cause for heavy menstrual bleeding and severe period pain.

Read on to learn more about adenomyosis and find out how UAE relieve heavy painful periods without hysterectomy.


Key Points:

Adenomyosis is endometriosis within the uterus.

It can cause debilitating heavy menstrual bleeding and period pain. It can also impair fertility and pregnancy.

Adenomyosis is often missed by ultrasound; MRI is more accurate.

Heightened awareness and suspicion are crucial to early diagnosis.

Adenomyosis often coexists with fibroids and endometriosis.

Hysterectomy is no longer the only solution.

Uterine Artery Embolization is an effective non-surgical alternative


What is adenomyosis?

Adenomyosis is like endometriosis within the uterine muscle wall. Adeno (glands) has grown into the uterine muscle wall (myosis).  Women with adenomyosis suffers from heavy menstrual bleeding (HMB), in addition to severe period pain. The uterus can be bulky due to reactive thickening of the muscle cells.

Adenomyosis can be found in up to 70% of hysterectomy specimens, and therefore may be far more common than appreciated clinically.

What are the causes of adenomyosis?

We don’t really completely understand what causes adenomyosis. However, there is the suggestion that previous uterine trauma of any kind can leads to development of adenomyosis. The risk factors are multiple pregnancies, termination of pregnancy, uterine curettage and caesarean section.

Adenomyosis is an oestrogen dependent condition and therefore women’s age, early on-set of menstruation, short menstrual cycles, obesity and Tamoxifen use are also risk factors. There is also association between adenomyosis, depression and use of antidepressant medications.

How is adenomyosis diagnosed?

Awareness and clinical suspicion are the keys to reaching an early diagnosis. Women with adenomyosis typically complain of HMB and severe period pain. The uterus can be enlarged and tender. Ultrasound operators may need to be alerted and prompted to look for the subtle signs of adenomyosis. MRI is more accurate than ultrasound in clinical practice.

Transvaginal ultrasound of a typical Adenomyosis.

Adenomyosis MRI

Adenomyosis MRI: Bright glandular tissue (adeno) invading the muscle layer (myosis).


How good is Mirena for adenomyosis?


Mirena slowly releases tiny does of progestrogen over 5 years.

A study from Turkey comparing Mirena and hysterectomy showed similar outcome in controlling heavy menstrual bleeding.

A study from China showed Mirena is also effective in reducing period pain. However, patient satisfaction rate was only 56.3% at 12 months. Common side effects such as prolonged light bleeding (25%) or irregular bleeding (14%), and other less common side effects such as weight gain, ovarian cyst formation, lower abdominal pain and acne contributed to the less than ideal satisfaction rate. Some women also report mood changes with Mirena.

More recent studies have shown Mirena is less effective in women with more extensive adenomyosis, if the uterus is larger than 150ml. A discontinuation rate of 70% is noted in women if the uterus is larger than 314ml.


What is UAE? How does UAE work?

Uterine Artery Embolisation (UAE) is an interventional radiology procedure. It is non-surgical and non-hormonal. UAE is performed under local anaesthetic and light sedation. It requires usually only a 1-night hospital stay and 1-week recovery.

A small catheter is navigated to the artery of the uterus.

During UAE, a small catheter is navigated to the artery of the uterus.

During UAE, a small tube (called catheter) is navigated under X-ray guidance to find the uterine arteries. Small particles suspended in X-ray dye are injected into the uterine arteries to block the blood supply. The adenomyotic tissue will die due to the lack of oxygen. Normal uterine muscle wall has many dormant arteries that can be recruited and therefore isn’t harmed.

Small particles suspended in X-ray dye are injected into the uterine arteries to block blood supply.

Particles are injected to block the artery of the uterus.

Watch the video: “How does UAE work for adenomyosis

How safe and effective is UAE?

UAE is the probably the most effective uterine-preserving treatment. Sydney Fibroid Clinic’s own patient satisfaction rate is 90% – meaning 90% of women treated were happy or very happy with the outcome of their UAE in relieving heavy menstrual bleeding and period pain.  There were no major complications.

UAE for Adenomyosis

46-year-old hair saloon manager has been suffering from HMB and severe period pain for 10 year. She failed Mirena due to prolonged bleeding and spotting. MRI showed diffuse adenomyosis with large cyst-like bright foci representing glands in the muscle layer that disappeared after UAE. She had a successful clinical outcome with resolution of her HMB and pain. She said her UAE was “liberating”.

Watch video: Elizabeth’s Life-Changing Story about her Adenomyosis and UAE

Is Ablation the right treatment for Adenomyosis?

Endometrial Ablation destroys the inner lining of the uterus.

Endometrial Ablation uses heat energy to destroy the inner lining of the uterus.

Endometrial ablation uses heat energy to destroy the inner lining of the uterus, so bleeding will be reduced.

However, glands in the muscle (adeno= glands; myosis in the muscle) will be trapped. Some have described this as “sealing off the juice on the BBQ hot plate”. Period pain and prementrual bloating can get worse following ablation. Even with modern technology, adenomyosis deeper than 2.5mm cannot be treated by ablation, according to a 2015 study.

If MRI is used for diagnosis, the minimal depth is 12mm . Therefore, adenomyosis diagnosed on MRI should not be treated with ablation.

In the past, when ablation failed to treat adenomyosis or if pain is worse after ablation, hysterectomy is to follow.

Today, there is an alternative to a hysterectomy.

If you had ablation and the pain has become worse, UAE might help to kill off adenomyosis tissue and alleviate pain.


Can adenomyosis be surgically removed?

Generally speaking, adenomyosis is not suitable for surgical removal. Adenomyosis is often a diffuse infiltrative process. Unlike fibroids, which can be easily separated from the normal uterine wall, adenomyotic tissue does not have a clear boundary with the normal myometrium.

Normal vs uterus affected by adenomyosis.

There is no clear boundary between adenomyosis and normal uterine wall and therefore cannot be effectively removed.

Surgeons often find it difficult to determine where adenomyosis stops and where normal myometrium starts. The removal is either incomplete, leaving behind adenomyotic tissue which can continue to grow and cause problems, or a larger than necessary amount of normal myometrium around the adenomyosis might have to be removed.

Surgeons might have been misled by an incorrect ultrasound diagnosis and inadvertently went ahead with surgery, with the intention of removing a “fibroid”. Half way through the surgery, it is then realized that the “fibroid” cannot be separated out from uterus and in fact it was adenomyosis that they are dealing with, and that surgery might need to be abandoned.

Is “wait for menopause” a good wisdom today?

Adenomyosis is an oestrogen dependent condition and will become worse during the perimenopause time. Periods remain heavy and painful, and the situation could be worse with added cycle unpredictability. If a woman requires hormone replacement therapy, the oestrogen component might worsen adenomyosis.

Is hysterectomy still “the only solution” in the 21st Century?

In the past, hysterectomy was seen as the only definitive treatment for women suffering from adenomyosis related symptoms. From early 2000, reports have emerged documenting the effectiveness of uterine artery embolisation (UAE) as an effective non-surgical alternative to hysterectomy.

How does adenomyosis affect fertility?

Adenomyosis has a negative impact on fertility and pregnancy. Women with adenomyosis are more likely to have premature delivery or pre-mature rupture of membranes.
Adenomyosis can also have a detrimental effect on IVF outcomes, reducing pregnancy rate and live birth rate.

How is adenomyosis related to endometriosis?

Unlike adenomyosis, endometriosis is due to ectopic endometrial tissue outside the uterus – anywhere else in the abdomen and pelvis. There is strong association between adenomyosis and endometriosis in up tp 80 to 90% of cases. If a woman is suffering from both HMB and pain, then the treatment should be aimed at adenomyosis. If the only symptom is period pain and medical imaging is negative for adenomyosis, then the focus should be on possible endometriosis. To diagnose adenomyosis, MRI scan is most accurate. To diagnose endometriosis, laparoscopy ( key-hole surgery / examination) is required, but is invasive and needs to be done under general anaesthetic.



Adenomyosis is under-recognised condition.  It can produce debilitating heavy menstrual bleeding and period pain. UAE is an effective treatment options for women who prefer to avoid hysterectomies.

Dr Eisen Liang is an Interventional Radiologist who founded Sydney Fibroid Clinic. He has worked collaboratively with gynaecologists for more than 10 years in helping women to resolve fibroid related symptoms. His research papers on fibroid disease have been presented internationally and published in ANZJOG.

For further information, please visit

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Many Australian women are troubled by fibroids symptoms such as heavy menstrual bleeding, period pain, bladder and pressure symptoms.

Often, they have been told to put up with it, wait for menopause, or have a hysterectomy.

Have you ever wondered if we can shrink fibroid without cutting out the uterus?

Thankfully we are in the 21st Century, there is now a much less invasive alternative to a hysterectomy. It is called UFE or Uterine Fibroid Embolisation.

Local anaesthetic, no surgical incisions, one night in hospital, one-week recovery-too good to believe?  Read on to find out more.

What is a uterine fibroid embolization (UFE)?

UFE (Uterine Fibroid Embolisation), also known as UAE (Uterine Artery Embolisation), is a minimally invasive radiological procedure that will shrink fibroids and alleviate fibroid symptoms such as heavy menstrual bleeding (HMB), period pain, pelvic pressure and bladder symptoms. Studies has shown that UFE is as effective as hysterectomy, but much less invasive with quicker recovery.

Haven’t heard about this? Well, your gynaecologist might not have mentioned UFE, which is performed by an Interventional Radiologist, not gynaecologists.

Minimally invasive radiological procedure that will shrink fibroids.

UFE Uterine Fibroid Embolisation-a non-surgical treatment.

How is UFE done?

UFE is performed under local anaesthetic and sedation. A small tube called catheter is inserted into the femoral artery in the groin. Using modern X-ray equipment, the catheter is then navigated to the arteries to the uterus. Small plastic particles (usually PVA polyvinyl alcohol) the size of sands are mixed with X-ray dye and injected to shut down the blood supply so that the fibroids will shrink and die. Patients stay overnight in hospital and may resume normal activities in one week.

During UFE, small particles are injected to block the arteries to the uterus.

During UFE, small particles are injected to block the arteries to the uterus.

Watch this video: How does UFE work?


How does UFE shrink fibroids without harming the normal uterus?

The uterus is a very special organ in human body. It is only about 60 to 80 ml when a woman is not pregnant. During pregnancy, we know that the uterus enlarges tremendously, carrying with it 40 times increase in blood flow. The uterus has an immense capacity to re-open and recruit dormant blood vessels when needed, like during pregnancy. Once the baby is born, the uterus shrivels down and most of the blood vessels also shut down.  Abnormal growths like fibroids do not have the ability to reopen or recruit blood vessels. Particles blocking the blood vessels supplying fibroid will lead to shrinkage. Some particles may enter normal myometrial tissue, causing transient lack of oxygen, but dormant vessels are then recruited to keep normal uterus alive. As a result, the fibroids die, and normal uterus remains alive.

UFE Shrinking Fibroid

Case Study 1: 43 year old teacher with a bulging abdomen
She also suffers from bloating and pressure symptom, as well as frequency of urination day and night. She is well and healthy otherwise, and she is not keen in major surgery. Note the marked reduction of fibroid volume from 533ml to 211ml at 6 month progress MRI; the fibroid is dead, no longer viable, seen as dark signal without contrast enhancement; the normal looking viable enhancing myometrium is labelled “M”. All her bladder symptoms have resolved. She is glad that she can fit her jeans again.

Does size and number matter for UFE?

No. UFE treats all fibroids, large or small, one or multiple are by the same procedure-blocking of the left and right uterine arteries by flowing in small particles. Therefore, the number of fibroids does not matter.

Size does not matter in general. On average, fibroid will shrink 60% of its volume. This amount of shrinkage is sufficient for symptom control in more than 90% of patients.

Fibroid shrinkage is related to the composition of the fibroid. Active fibroids that are rich in cells and blood suppl tend to shrink more, than “fibrous” or less active fibroids.

Shrinking Fibroids through UFE.

Case Study 2: 48 year old wife of a doctor failing conservative treatments
She suffers from severe heavy menstrual bleeding (HMB) and failed conservative treatments including removal of some of the fibroids and Mirena. She continued to suffer from HMB but declined hysterectomy. Pre-UFE MRI showed multiple fibroids denoted as “F”. After UFE, fibroids are shrunken, scarred and no longer viable, seen as dark nodules. The uterine volume reduced from 781ml to 349ml. Her periods become very light and she is very happy –”UFE changed my life”.

How effective is UFE?

UFE was first reported in 1995. Since then many research studies have document the effectiveness. There are now 7 randomised control trials (RCTs) comparing UFE with surgery (myomectomy or hysterectomy). The results were summarised by Cochrane review in 2014. Cochrane is the highest level of medical evidence when it comes to comparing treatment options. Cochrane stated that UFE has similar outcome compare with surgery, in terms of symptom relief, patient satisfaction and quality of life improvement. In other words, UFE is as effective as hysterectomy, but less invasive and with quicker recovery.

Watch Video: UFE on Channel 7 News

How soon do we see the effect of UFE?

For heavy periods, quite often the menstrual loss is noticeably reduced at the first menstrual period after UFE. Pressure and bladder symptoms might take 2-3 months to be noticeably relieved.

Is pregnancy possible after UFE?

Many research studies suggest pregnancy is possible after UFE. There seems to be no foetal growth retardation. However, when compared with a general obstetric population, the rate of miscarriage, pre-term delivery and post-partum haemorrhage is higher in women who have undergone UFE.  This is probably related to the fibroid disease itself rather than the UFE procedure.


UFE is a minimally invasive angiographic procedure that has been proven to be safe and effective to treat fibroid related symptoms. It is performed under local anaesthetic, requires 1-night stay in hospital and 1-week recovery. It is most suitable for women who wish to avoid a hysterectomy.


Dr Eisen Liang is an Interventional Radiologist who founded Sydney Fibroid Clinic. He has worked collaboratively with gynaecologists for more than 10 years in helping women to resolve fibroid related symptoms. His research papers on fibroid disease have been presented internationally and published in ANZJOG.

 For further information, please visit

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