What is the Difference Between Endometriosis and Adenomyosis?

Endometriosis is a medical condition in which tissue similar to the lining of the uterus (endometrium) grows outside the uterus, causing severe pain during menstruation and during/after sexual intercourse. Endometriosis also affect bowel movements and/or urination and can cause chronic pelvic pain, abdominal bloating, nausea, fatigue, mental health issues, heavy bleeding and sometimes fertility issues. The majority of women with Endometriosis will experience symptoms like the ones listed above, but a small percentage of women may actually be asymptomatic, and have endometriosis without any symptoms. Endometrial tissue can grow in a number of places in the body (some tissue has been found in the lungs and on the thumb) but it most commonly grows on the ovaries, fallopian tubes and tissue lining the pelvis.

Adenomyosis is a gynecological condition characterised by the presence of endometrial tissue (the lining of the uterus) growing into the muscular wall of the uterus (myometrium). This abnormal growth can lead to an enlarged and painful uterus, causing symptoms such as heavy menstrual bleeding, severe pelvic pain, abdominal bloating and other digestive issues and consequent mental health problems. There are two main types of adenomyosis: diffuse adenomyosis, where the abnormal tissue growth is spread throughout the uterine wall, and focal adenomyosis, where the growth is limited to specific areas or regions within the uterus. Both types can cause significant discomfort and may require medical intervention for symptom management.

It is possible to have either one of these conditions independently or have both at the same time. A 2017 study of 300 women diagnosed with adenomyosis found that 42.3% also had endometriosis. It is also possible that these conditions feed into each other and development of one of the condition may lead to the development of the other. The exact cause of endometriosis and adenomyosis remains unknown, these is also much less research available around adenomyosis, but both the conditions seems to have the same etiology. The only real difference between the two is the location of the endometrial lesions which can then lead to slightly different symptoms and treatment approaches.

How is Endometriosis  and Adenomyosis Diagnosed?

Transvaginal Ultrasound: Transvaginal ultrasound involves inserting a probe into the vagina to create images of the pelvic organs. It can help identify endometriotic cysts (endometriomas) in the ovaries, large endometrial growths, and structural abnormalities. While this technique can be helpful, it may not always detect small or subtle endometriotic lesions, especially in the early stages of the disease. It is also operator-dependent, meaning the skill and experience of the sonographer can influence the accuracy of the results.

Magnetic Resonance Imaging (MRI):  Provide valuable information about the location and extent of endometriosis and adenomyosis. MRI is particularly useful in pre-surgical planning to help the surgeon understand the extent of the disease. However, like ultrasound, MRI also has limitations in detecting small endometriotic lesions, and it may not always definitively differentiate endometriosis and adenomyosis from other conditions with similar appearances.

Hysteroscopy:  A thin, lighted tube (hysteroscope) is inserted through the vagina and cervix to examine the uterine cavity and collect tissue samples for further analysis. This can help determine if the uterus is enlarged and lead to a potential diagnosis of adenomyosis.

Laparoscopy: a definitive diagnosis of endometriosis can only be made through a surgical procedure called laparoscopy. During the laparoscopy, a thin tube with a camera (laparoscope) is inserted into the abdomen through a small incision, allowing the doctor to visualise and examine the pelvic organs for any endometrial growths, scar tissue, or adhesions. The laparoscopy not only confirms the presence of endometriosis but also helps determine the extent and severity of the condition. In some cases, the doctor may take tissue samples (biopsies) during the laparoscopy for further analysis to rule out other conditions.

Conventional Treatment Options for Endometriosis and Adenomyosis

Treatment options for endometriosis can vary depending on the severity of symptoms and the individual’s specific case.

1. Pain Medications: Over-the-counter pain relievers like ibuprofen or naproxen can help manage mild to moderate pain. For more severe pain, a doctor may prescribe stronger pain medications.
2. Birth Control: Hormonal birth control methods, such as combination pills, progestin-only pills, patches, or hormonal intrauterine devices (IUDs), can help control pain and reduce the growth of endometrial tissue. The marina IUD is a popular choice that can be inserted during a laparoscopy if appropriate. While these medications may work to improve symptoms, they also cary side effects, especially for mental health.
3. Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists: These medications lower estrogen levels, inducing a temporary menopause-like state to suppress endometriosis growth and reduce symptoms.
4. Progestin Therapy: Progestin hormones, available as pills, injections, or IUDs, can help relieve pain and slow the growth of endometrial tissue. These medications also carry side effects.
5. Aromatase Inhibitors: These medications block the production of estrogen and may be used in combination with other hormonal therapies for endometriosis treatment.
6. Danazol: This synthetic hormone suppresses ovulation and menstruation, reducing endometrial tissue growth. However, it may have significant side effects and is not commonly used as a first-line treatment.
7. Conservative Surgery: Laparoscopic surgery can be performed to remove endometrial growths (endometriomas) and adhesions. This approach aims to preserve the uterus and ovaries for women who wish to conceive in the future. This approach is successful at reducing pain for up to 2 years, however after this time most endometrial lesions will regrow and pain can return. This is surgery for endometriosis.
8. Uterine Artery Embolization (UAE) : In this minimally invasive procedure, tiny particles are injected into the arteries that supply blood to the uterus, reducing blood flow to the abnormal tissue and alleviating symptoms. This is usually only for adenomyosis.
9. Endometrial Ablation: for adenomyosis: This procedure involves the removal or destruction of the endometrial lining, which can provide relief from heavy menstrual bleeding. This is more common for adenomyosis but can be considered for both endometriosis and adenomyosis.
10. Hysterectomy: In severe cases, when other treatments have failed or for women who no longer wish to have children, a hysterectomy (removal of the uterus) may be recommended. This may or may not include removal of the fallopian tubes and ovaries depending on the location of endometriosis and a woman’s personal choice.

Gut Health and its Impact on Endometriosis and Adenomyosis

Women with endometriosis are 2-3 times more likely to also suffer from irritable bowel syndrome and have lower microbial diversity of beneficial bacteria than women without endometriosis (1) (2).  Similarly adenomyosis sufferers are found to have microbial dysbiosis in the gut and vagina (3). Emerging research suggests a link between gut health and endometriosis particularly regarding lipopolysaccharide (LPS) toxin from the gut. LPS is a harmful bacterial endotoxin commonly found in the outer membrane of certain types of bacteria. More LPS is present with the overgrowth if unfavourable bacteria in the gut. This is seen often in small bacterial overgrowth (SIBO). When LPS enters the bloodstream through a compromised gut barrier (leaky gut) it can activate macrophages ( a type of immune cell). Once activated, macrophages release pro-inflammatory cytokines, leading to systemic inflammation and inflammation in the pelvic cavity.   The combination of LPS and estrogen seem to initiate the growth of endometrial tissue (5). This has lead to the ‘bacterial contamination theory of endometriosis’ (6) indicating a possible causitive role in disease pathogenesis of endometriosis and adenomyosis.

It’s important to note that the link between LPS, gut health, and endometriosis is an area of active research and more needs to be discovered before appropriate treatment options can be found, however working on gut heath to correct underlying dysbiosis may have huge impact on helping to resolve endometrial symptoms and prevent the growth of endometrial tissue. Bacterial overgrowth should be addressed through good eating habits that involve allowing adequate time between meals for digestion (4-6 hours) and a sufficient overnight fast of 12-14, aiming for no food intake at least 3 hours before bed time. This allows time for the migratory motor complex to help sweep out undigested food particles including unwanted bacteria out of the system. Gut healthy diets also include a wide variety of anti-inflammatory plant foods, aiming for a minimum of 30 different plant foods per week and reducing exposure to unhealthy processed foods, saturated fats, processed meats, red meats as well as refined sugars, refined flours and potentially dairy. (Read my article about gut health here) .

In many cases treatment of bacterial overgrowth with herbal anti-mocrobials or targeted antibiotics is necessary alongside making dietary changes to support gut health. Treatment to help repair gut lining and prevent against leaky gut is usually also warranted. Seek professional help.

Autoimmunity & Inflammation

Endometriosis and Adenomyosis have been associated with potential links to autoimmunity, although the exact nature of this relationship remains an area of ongoing research. Inflammation is often at the root of autoimmunity and autoimmunity further exacerbates inflammation.  Autoimmunity occurs when the body’s immune system mistakenly attacks its own tissues, leading to inflammation and damage. In endometriosis, the presence of endometrial-like tissue outside the uterus can trigger an immune response, causing chronic inflammation and the formation of adhesions and scar tissue. Additionally, some studies suggest that women with endometriosis and adenomyosis may have alterations in immune function, including abnormal immune cell activity and changes in inflammatory cytokines (7)(8). These immune system dysregulations could contribute to the development and progression of both these conditions.

Although it is too soon to say wether endometriosis and adenomyosis are  in fact an autoimmune conditions, adopting an autoimmune supportive lifestyle may reduce inflammation and potentially ease symptoms. The best natural treatment for autoimmune conditions includes working on correcting gut health, specifically healing the gut lining and treating intestinal permeability. This reduces systemic inflammation which then lowers the autoimmune response. Additionally supporting the immune system with adequate rest, stress reduction and ensuring adequate vitamin d and essential nutrients like selenium, zinc and vitamin c can help improve the immune response and calm inflammation. An anti-inflammatory diet is also widely promoted for helping to ease endometriosis symptoms. Anti-inflammatory diets include a wide variety of fruits, vegetables, whole-grains, legumes, nuts and seeds and healthy oils (especially omega 3) with minimal animal products, processed foods, highly refined foods and sugary foods and beverages.

Because many autoimmune conditions often occur alongside other autoimmune conditions (9) in the case of endometriosis and adenomyosis it may be worth investigating other autoimmunities such as Hashimotos thyroiditis or celiac disease and receiving appropriate treatment eg. gluten free. Both these conditions have been associated with intestinal permeability and so the likelihood of having more than one autoimmune condition increases.

Estrogen Dominance

Estrogen promotes the growth and maintenance of the endometrial tissue lining the uterus. Estrogen fuels the growth and proliferation of abnormal endometrial tissue during the menstrual cycle, contributing to pain, inflammation, and other symptoms associated with the conditions (10). The impact of estrogen fluctuations on endometriosis and adenomyosis are so large that to date, the majority of treatment options for these conditions have involved lowering estrogen through suppression of the menstrual cycle. Hormonal therapies, such as birth control pills, progestins, and GnRH agonists, work to modulate estrogen levels and suppress endometrial tissue growth, providing relief for many individuals with endometriosis and/or adenomyosis. However these treatments come with often severe side-effects. A lot can be done to help lower unfavourable estrogen metabolites naturally through gut health, liver and gall bladder health, stress management and reducing environmental exposure to estrogens. A focus on cruciferous vegetables, iodine rich foods as well as phytoestrogen rich foods like flax seeds, soy foods and pomegranates can play a big role in modulating estrogen receptors and enhancing the metabolism and clearance of estrogen out of the body. There are also many natural herbal remedies that may help. ( Read my article about understanding estrogen dominance here🙂

Environmental estrogens, found in certain chemicals and pollutants, can mimic the effects of natural estrogen in the body. Exposure to these endocrine disruptors may contribute to estrogen dominance and worsen endometriosis symptoms. Reducing exposure to both environmental estrogens and endogenous estrogens is important for endometriosis/adenomyosis management. This is achieved by avoiding alcohol, reducing intake of meat, dairy and artificial food additives and preservatives, choosing non toxic beauty and sanitary products, choosing non toxic cleaning products, non toxic cooking utensils and reducing exposure to plastics, especially in food and drink eg. heating food in plastic containers.

Reducing Stress and Trauma for Pain Management

There is a biological connection between stress, trauma and physiological symptoms. In a large study, as many as 79% of women who had endometriosis also reported childhood abuse in various forms (11)(12). While this is just an association and not causative, it does highlight the importance of also addressing mental health and past traumas in the management and treatment of any disease. Aside from psychological implications,  stress is known to exacerbate pain and inflammation as well as increase unfavourable estrogen in the body.  For this reason I would encourage all women with endometriosis to seek psychological support, both to help with the real mental implications of living with a chronic disease that causes debilitating pain, but also to heal from past traumas that may be keeping their body in a state of ongoing heightened stress.

Conclusion

While diet and lifestyle changes can significantly improve endometriosis/adenomyosis symptoms and overall quality of life, it’s essential to acknowledge that they may not be enough for everyone. Endometriosis is a complex condition, and its management often requires a multidisciplinary approach.  Depending on the severity of the condition, appropriate medical treatments such as surgery or medication may be warranted.

References:

1.Nabi, M. Y., Nauhria, S., Reel, M., Londono, S., Vasireddi, A., Elmiry, M., & Ramdass, P. V. A. K. (2022). Endometriosis and irritable bowel syndrome: A systematic review and meta-analyses. Frontiers in medicine, 9, 914356. https://doi.org/10.3389/fmed.2022.914356

2.Svensson, A., Brunkwall, L., Roth, B., Orho-Melander, M., & Ohlsson, B. (2021). Associations Between Endometriosis and Gut Microbiota. Reproductive sciences (Thousand Oaks, Calif.), 28(8), 2367–2377. https://doi.org/10.1007/s43032-021-00506-5

3.Lin, Q., Duan, H., Wang, S., Guo, Z., Wang, S., Chang, Y., Chen, C., Shen, M., Shou, H., & Zhou, C. (2023). Endometrial microbiota in women with and without adenomyosis: A pilot study. Frontiers in microbiology, 14, 1075900. https://doi.org/10.3389/fmicb.2023.1075900

4.Sztachelska, M., Ponikwicka-Tyszko, D., Martínez-Rodrigo, L., Bernaczyk, P., Palak, E., Półchłopek, W., Bielawski, T., & Wołczyński, S. (2022). Functional Implications of Estrogen and Progesterone Receptors Expression in Adenomyosis, Potential Targets for Endocrinological Therapy. Journal of clinical medicine, 11(15), 4407. https://doi.org/10.3390/jcm11154407

5.Khan, K. N., Kitajima, M., Inoue, T., Fujishita, A., Nakashima, M., & Masuzaki, H. (2015). 17β-estradiol and lipopolysaccharide additively promote pelvic inflammation and growth of endometriosis. Reproductive sciences (Thousand Oaks, Calif.), 22(5), 585–594. https://doi.org/10.1177/1933719114556487

6.Khan, K. N., Fujishita, A., Hiraki, K., Kitajima, M., Nakashima, M., Fushiki, S., & Kitawaki, J. (2018). Bacterial contamination hypothesis: a new concept in endometriosis. Reproductive medicine and biology, 17(2), 125–133. https://doi.org/10.1002/rmb2.12083

7.Nothnick W. B. (2001). Treating endometriosis as an autoimmune disease. Fertility and sterility, 76(2), 223–231. https://doi.org/10.1016/s0015-0282(01)01878-7

8.Ota, H., Igarashi, S., Hatazawa, J., & Tanaka, T. (1998). Is adenomyosis an immune disease?. Human reproduction update, 4(4), 360–367. https://doi.org/10.1093/humupd/4.4.360

9.Cojocaru, M., Cojocaru, I. M., & Silosi, I. (2010). Multiple autoimmune syndrome. Maedica, 5(2), 132–134.

10.Bulun, S. E., Monsavais, D., Pavone, M. E., Dyson, M., Xue, Q., Attar, E., Tokunaga, H., & Su, E. J. (2012). Role of estrogen receptor-β in endometriosis. Seminars in reproductive medicine, 30(1), 39–45. https://doi.org/10.1055/s-0031-1299596

11.Fiala, L., Lenz, J., & Bob, P. (2021). Effect of psychosocial trauma and stress on sexual dysfunction in women with endometriosis. Medicine, 100(31), e26836. https://doi.org/10.1097/MD.0000000000026836

12.Holly R Harris and others, Early life abuse and risk of endometriosis, Human Reproduction, Volume 33, Issue 9, September 2018, Pages 1657–1668, https://doi.org/10.1093/humrep/dey248