Adenomyosis, often called “endometriosis interna,” is a complex gynaecological condition that shares many similarities with external endometriosis. Both conditions lead to debilitating symptoms such as heavy and prolonged menstrual bleeding, severe cramping (dysmenorrhea), chronic pelvic pain, painful intercourse (dyspareunia), and, in many cases, infertility. These symptoms can significantly impact the quality of life for women, making timely diagnosis and appropriate treatment essential.

According to Dr Sanjay Patel, an Endometriosis Surgeon at Mayflower Women’s Hospital in Ahmedabad, the co-occurrence of adenomyosis with endometriosis is not uncommon, and understanding the intricate nature of both conditions is crucial for effective treatment. "Adenomyosis can increase the likelihood of external endometriosis, and both conditions contribute to overlapping symptoms," says Dr Patel. "This makes it important for physicians to distinguish between the two and develop tailored treatment plans."

Dr Patel has faced numerous challenges in diagnosing adenomyosis since the mid-90s. One of the major hurdles has been determining the severity of the disease. Adenomyosis presents itself in two forms: focal (localized) tissue growth and diffuse disease, which spreads across the myometrium, the muscular wall of the uterus. This dual presentation complicates diagnosis, as merely estimating the size of focal growths does not provide a complete picture of the disease’s impact.

Historically, physicians would estimate the size of the uterus in terms of pregnancy weeks to gauge the severity of adenomyosis. However, Dr. Patel noted that this method offered only a partial understanding of the condition. "It became clear that we needed a standardized classification system that would account for both the size of focal growths and the extent of diffuse disease," he explained.

The diagnosis of adenomyosis typically begins with transvaginal ultrasonography. This imaging method can reveal specific characteristics such as posterior thickening of the myometrium, myometrial cysts, and radiating linear striations extending from the endometrium. Additionally, the loss of a clearly defined endometrial border and increased vascularity in the affected region can also be observed using Color Doppler imaging, which highlights the adenoma’s margins.

For a more detailed assessment, Dr. Patel often recommends an MRI, which provides a clearer picture of the disease's progression. MRI scans can detect focal masses, cystic formations, and disease spread to other parts of the pelvis. This advanced imaging helps clinicians to understand the full extent of the disease and tailor their treatment plans accordingly.

A New Classification of Adenomyosis

To provide clarity for surgeons and aid in choosing the appropriate treatment paths, Dr. Patel developed a standardized classification system for adenomyosis. This classification divides the condition into five stages based on the size of the focal masses and the extent of the diffuse disease spread.

1. Grade IA: Small, localized lesions up to 3 cm. This is the mildest form of adenomyosis with minimal spread.

2. Grade IB: Diffuse disease spread across both the posterior and anterior uterus, accompanied by smaller localized lesions.

3. Grade IIA: Larger focal masses (greater than 3 cm), often combined with diffuse disease or additional smaller focal growths in other areas of the uterus.

4. Grade IIB: Diffuse disease affecting up to 50 per cent of the uterus. The extent of diffusion plays a key role in determining the treatment strategy.

5. Grade III: The diffuse disease has taken over the entire uterus. In this advanced stage, the tissue becomes densely vascular and challenging to delineate, complicating surgical planning.

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