Endometriosis and adenomyosis are the debilitating reproductive conditions often referred to – not-so-lovingly – as cousins. Why? Because they both deal with tissue overgrowth – but they are not the same, and the difference doesn’t merely lie in awareness. Let’s dive in. 

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Adenomyosis and endometriosis are two distinct but often overlapping conditions that can have significant impacts on women's health and quality of life – with delayed diagnoses, poor medical treatment plaguing the field, it’s no wonder there are so many misunderstandings around the conditions. Medical gaslighting and dismissal are all too common for women dealing with endometriosis – and, really, any condition. Read about Bindi Irwin’s shocking endometriosis story, along with IQS’s own Clara Mearns’ experience with the condition and her battle to get diagnosed. 

What Endometriosis + Adenomyosis Have in Common

Both Involve Abnormal Growth of Endometrial Tissue: One of the primary similarities between adenomyosis and endometriosis is the presence of endometrial-like tissue outside its usual location. In adenomyosis, this tissue grows into the muscular wall of the uterus (myometrium), while in endometriosis, it implants and grows outside the uterus, commonly on the ovaries, fallopian tubes, and pelvic peritoneum.

Shared Symptoms: Adenomyosis and endometriosis both manifest with symptoms such as pelvic pain, dysmenorrhea (menstrual cramps), dyspareunia (painful intercourse), and irregular menstrual bleeding. These symptoms can vary in severity and may significantly impact individuals' quality of life – and it’s a major reason why so many adenomyosis sufferers are left without a diagnosis.

Overlap in Risk Factors and Associations: Both adenomyosis and endometriosis are associated with similar risk factors, including a family history of the condition and early onset of menstruation. Additionally, individuals with one condition may be at increased risk of developing the other, suggesting potential shared underlying mechanisms.

Diagnostic Challenges: Diagnosing adenomyosis and endometriosis can be challenging due to their nonspecific symptoms and the need for specialized imaging or invasive procedures for definitive diagnosis. Both conditions may be underdiagnosed or misdiagnosed, leading to delays in appropriate management and treatment.

Impact on Fertility and Reproductive Health: Adenomyosis and endometriosis can both affect fertility and reproductive health, leading to difficulties conceiving, recurrent pregnancy loss, and pregnancy complications. The presence of either condition may necessitate fertility treatments or interventions to achieve pregnancy.

How Endometriosis + Adenomyosis Differ

Anatomical Location of Lesions: One of the primary differences between adenomyosis and endometriosis is the anatomical location of the lesions. Adenomyosis involves the infiltration of endometrial-like tissue into the myometrium of the uterus, whereas endometriosis typically involves lesions outside the uterus, such as on the ovaries, fallopian tubes, and pelvic peritoneum – but this tissue has been known to spread to basically every part of the body, brain included!

Pathophysiology and Etiology: Okay, okay let's unpack the science jargon – what exactly do these words mean, you ask? Well pathophysiology refers to the study of the functional changes that occur in the body as a result of a disease or abnormal condition, looking into the development, progression, and manifestations of a disease, including changes at the cellular, tissue, organ, and systemic levels. Etiology, on the other hand, refers to the study of the causes or origins of a disease. It involves identifying the factors that contribute to the development or initiation of a disease process – think genetic predisposition, environmental exposures, infections, hormonal imbalances, immune dysfunction and lifestyle factors. With that out of the way, let’s unpack how these differ in adenomyosis and endometriosis. Adenomyosis is characterised by the invasion of endometrial tissue into the myometrium, possibly due to disruption of the uterine lining or hormonal imbalances, while endometriosis involves the presence of endometrial-like tissue outside the uterus, with theories including retrograde menstruation, immune dysfunction, and genetic predisposition.

Appearance on Imaging Studies: While both adenomyosis and endometriosis may be visualised on imaging studies such as ultrasound or magnetic resonance imaging (MRI), they have different characteristic appearances. Adenomyosis typically presents as diffuse thickening of the uterine wall with heterogeneity on imaging, whereas endometriosis may appear as discrete lesions or nodules in the pelvic cavity.

Adenomyosis typically presents with characteristic findings on imaging studies such as ultrasound and MRIs:

• On ultrasound, adenomyosis may appear as diffuse thickening of the uterine wall, often with asymmetrical involvement and loss of the normal distinct border between the junctional zone and the outer myometrium.
• The affected area may exhibit heterogeneity, hypoechoic regions, or cystic spaces within the myometrium. Doppler ultrasound may demonstrate increased vascularity within the adenomyotic lesions.
• Adenomyosis may also be associated with diffuse uterine enlargement and asymmetry on MRI.

Endometriosis lesions can have variable appearances on imaging studies depending on their location and characteristics.

• On ultrasound, endometriotic lesions may appear as discrete hypoechoic or cystic structures within the pelvic cavity, commonly involving the ovaries (endometriomas), peritoneum, or other pelvic organs.
• Endometriomas typically present as well-defined cystic masses with homogeneous low-level internal echoes, often referred to as a "ground-glass" appearance.
• MRI is considered the imaging modality of choice for evaluating endometriosis due to its superior soft tissue contrast and multiplanar capabilities.

Treatment Approaches: Treatment approaches for adenomyosis and endometriosis may differ based on the severity of symptoms, reproductive goals, and individual preferences. While hormonal therapies such as oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) agonists may be used to manage symptoms of both conditions, surgical interventions such as hysterectomy or excision of endometriotic lesions are more commonly considered for severe or refractory cases of endometriosis.

Potential for Disease Progression and Recurrence: Adenomyosis and endometriosis may differ in their patterns of disease progression and recurrence. Adenomyosis may progress with age or hormonal changes, potentially worsening symptoms over time. Endometriosis may also recur following surgical treatment, requiring ongoing management and surveillance to prevent symptom recurrence.

So Why Do They Get Mixed Up? 

Diagnosing adenomyosis and endometriosis can be challenging due to their nonspecific symptoms and the need for specialised imaging or invasive procedures for definitive diagnosis. Both conditions may be underdiagnosed or misdiagnosed, leading to delays in appropriate management and treatment. It's also not uncommon for individuals to have both adenomyosis and endometriosis concurrently, a phenomenon known as "coexistent adenomyosis and endometriosis." In such cases, distinguishing between the two conditions based on clinical presentation alone can be particularly challenging, and imaging or surgical evaluation may be necessary for accurate diagnosis. Studies have reported varying prevalence rates of coexistent adenomyosis and endometriosis, ranging from approximately 20% to 70% among individuals undergoing surgical evaluation for pelvic pain, infertility, or other gynaecological concerns. The exact prevalence may vary depending on the study population, diagnostic criteria, and methods used for evaluation.

Despite being relatively common gynaecological conditions, adenomyosis and endometriosis may not receive the same level of awareness or attention as other reproductive health issues. This lack of awareness among both healthcare providers and the general public can contribute to misconceptions and diagnostic delays. Overall, while adenomyosis and endometriosis share similarities in symptoms and risk factors, they are distinct conditions with different anatomical locations, pathophysiological mechanisms, and treatment approaches. Recognising and understanding these differences is essential for accurate diagnosis and appropriate management of individuals with these conditions.

Head on over to Endometriosis Australia for more information on the condition and how to support its research and treatment.

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