J Gandhara Med Dent Sci

January - March 2025

ORIGINAL ARTICLE

UNDERSTANDING THE COEXISTENCE OF ADENOMYOSIS AND UTERINE FIBROIDS IN

PATIENTS WITH ENDOMETRIOSIS TO ENHANCE TREATMENT AND FERTILITY OUTCOMES

Hina Niaz1, Dure Nayab2, Asaf Alam Khan3

How to cite this article

Niaz H, Nayab D, Khan AA.

Understanding the Coexistence of

Adenomyosis and Uterine Fibroids in

Patients with Endometriosis to Enhance

Treatment and Fertility Outcome. J

Gandhara Med Dent Sci. 2025;12(1):

7-10.doi:10.37762/jgmds.12-1.617

Date of Submission: 21-09-2024

Date Revised: 30-10-2024

Date Acceptance: 20-11-2024

1Postgraduate Trainee, Department of

Gynae A ward, Khyber Teaching

Hospital, Peshawar

3Trainee Registrar, Department of

Cardiology, Khyber Teaching

Hospital, Peshawar

Correspondence

1Hina Niaz, Experiential Registrar,

Gynae A Unit, Khyber Teaching

Hospital

+92-332-9265356

drhinaniaz11@yahoo.com

ABSTRACT

OBJECTIVES

This study investigated the coexistence of adenomyosis and uterine broids in

individuals diagnosed with endometriosis. This research seeks to contribute

to understanding how these conditions interact, aiming to improve treatment

strategies and enhance patient fertility outcomes.

METHODOLOGY

This study aims to evaluate 250 patients suspected of endometriosis with the

help of clinical investigation and ultrasound (US). From the US study, we

examined the existence of endometriosis with either uterine broid or

adenomyosis based on patient age groups (less than 32 years, 33 to 42 years,

and 43 and above). In addition, ovarian endometriosis and profoundly

inltrating endometriosis were evaluated.

RESULTS

US study diagnosed adenomyosis in 3.2% of cases, broids in 21.8%, and the

coexistence of both broid and adenomyosis in 14.2% of the cases. Intranural

broids were found at 11.4%, submucous broids 1.6% and subserous at

8.1% of the total. Patients with an age of more than 33 years were more

aected by adenomyosis, uterine broids, and both adenomyosis and uterine

broid. There was no statistically signicant correlation between uterine

diseases and endometriosis. Additionally, no correlation was found between

endometriosis and the patient’s age.

CONCLUSION

Our ndings indicate that women over 32 are more likely to experience these

comorbidities, complicating infertility outcomes. The signicant association

between adenomyosis and severe endometriosis reinforces the need for

comprehensive diagnostic evaluation to inform tailored treatment plans.

Future research should investigate the interactions between these conditions

further to improve diagnostic and therapeutic approaches.

KEYWORDS: Endometriosis, Adenomyosis, Infertility, Uterine Fibroids

INTRODUCTION

Endometriosis is a complex and chronic inammatory

condition aecting 6-10% of women of reproductive

age and can cause either pain or infertility.1,2

Endometriosis is categorized into three phenotypes:

deep inltrating endometriosis (DIE), supercial

peritoneal endometriosis (SUP), and ovarian

endometriosis (OMA), based on pelvis ectopic tissues.3

According to a study, approximately 30-50% of women

diagnosed with endometriosis face challenges to

achieve pregnancy.4 The presence of uterine broids in

endometriosis patients, originating from histological

and surgical reports, was also reported in a study. It was

found that 25.8% of the patients had uterine broids

and were undergoing surgery for endometriosis.5

According to a surgical report, endometriosis and

adenomyosis were present in 40.4% of patients who

underwent a hysterectomy for benign uterine illnesses,

while endometriosis and uterine broids were present

in 22.7%, and both problems in 34.1% of patients.6 A

cohort study determined that reproductive-age women

(below 35 years of age) who have endometriosis were

at high of infertility in comparison to women without

endometriosis.7 As less data is available about the

occurrence of adenomyosis in women having

endometriosis, the main aim of the study was to

evaluate the clinical examination and analyze the

sonographic prevalence of uterine broid and

adenomyosis in endometriosis patients by considering

dierent age intervals in Khyber Teaching Hospital,

KP , Peshawar.

8J Gandhara Med Dent Sci

January - March 2025

METHODOLOGY

The study was conducted at a Khyber Teaching

Hospital, KP, Peshawar, Pakistan, on women suspected

of endometriosis by clinical investigation and

ultrasound from 2021-2023. After the approval of the

ethical committee, patients (n=250) were subjected to

transvaginal ultrasound evaluation by expert-

sonographers. The patients included were of

reproductive age between 25 to 45 years, having

ultrasound lesions indicated endometriosis. Data

collected during ultrasound and clinical investigation

were analyzed, and an electronic database was created.

Two expert gynecologists in gynecological ultrasound

performed the scan with the help of an ultrasound

machine (Voluson E8, GE). Dur ing the examination,

the adnexa, uterus, and pelvic compartments were

evaluated for endometriosis, uterine broids, and

adenomyosis. Localized endometriosis lesions were

defined by International Tumor Analysis (IOTA)

criteria, detecting the ultrasound-homogenous “tissue”

with ground glass appearance.8 International Deep

Endometriosis Analysis (IDEA) described deep

inltrating endometriosis by the appearance of

spherical lesions with or without regular contours.9

Furthermore, the adenomyosis and broids were

dened by considering Morphological Uterus

Sonographic Assessment (MUSA) criteria by well-

dened circular lesions with shadows at the edge within

the myometrium. Adenomyosis was described as focal,

diuse, or cystic adenomyosis by investigating an

enlarged uterus with regular or irregular thickened

junctional zone; interruption; ill-defined myometrial

lesions, shape; no edge mixed type echogenicity with

translesional vascular ow and cyst.10 In this study, a

total number of 183 patients who had US-conrmed

endometriosis were investigated. The study consisted of

10% of women having a previous history of surgery for

endometriosis, while the remaining women were rst

time suspected for endometriosis examination by

clinical and ultrasound methodology.

RESULTS

A total number of 250 patients were evaluated for

endometriosis, and 183 cases were conrmed with the

help of ultrasound. Figure.1 presents the owchart of

the total patients and the subgroups based on the

endometriosis phenotype. Gynecological comorbidities

and characteristics of the uterine disorder are shown in

Table 1. It was observed that uterine broids were in

3.2% of the patients, adenomyosis in 21.85%, while

both adenomyosis and uterine broids coexisted in

14.2% of the total cases. Most broids were intramural

and 11.4%, submucous were 1.6%, and subserous

myomas were 8.1%. Comparing the prevalence of

gynecological comorbidities based on age dierences,

it was determined that the patients aged> 32 years were

affected more by uterine broids (p =0.004),

adenomyosis, (p=0.031) and adenomyosis and uterine

fibroids (p <0.0001). No signicant correlation was

found between uterine disorder and endometriosis.

Moreover, also no association was found between

endometriosis phenotype and patient age (Table 2 and

Table 3)

Figure 1:

Table 2: Shows Various Pathologies and Their Prevalence When

Diagnosed on CT Head

Age < 32

years

n= 84

(45.9%)

Age >32

years < 42

years n=79

(43.17)

Age >42

years

n= 20

(10.92)

P-Value

Endometriosis Phenotypes

OMA 47/84

(55.9%)

48/79

(60.7%)

11/20

(55%) 0.375

DIE 17/84

(20.23%)

17/79

(21.5%)

04/20

(20%) 0.872

Both OMA

and DIE

20/84

(23.80%)

14/79

(17.72%)

05/20

(25%) 0.174

Uterine Disorder Comorbidities

Uterine

broids

15/84

(17.85%)

5/79

(6.3%)

02/20

(10%) 0.004

Adenomyosis 6/84

(7.14%)

21/79

(26.58%)

05/20

(25%) 0.031

Both Uterine

broids and

Adenomyosis

6/84

(7.14%)

15/79

(18.98%)

07/20

(31.8%) <0.0001

Table 1: Gynecological Comorbidities in Patients with US

Diagnosis of Endometriosis

Submucous 3/183 (1.6%)

Intramural 21/183(11.4%)

Subserous 15 /183(8.1%)

Polycystic-Ovary Ultrasound Appearance

Yes 18/183 (9.8%)

No 165/183(90.16%)

Characteristics

Mean age (years) 35.6

Uterine Disorder Comorbidities

Uterine broids 6/183 (3.2%)

Adenomyosis 40/183(21.8%)

Uterine broid and adenomyosis 26/183(14.2%)

Types of Uterine Fibroids

Understanding the Coexistence of Adenomyosis andUterine Fibroids

J Gandhara Med Dent Sci

January - March 2025

Table 3: Uterine Disorder According to Phenotype in Women

with Endometriosis

Ovarian -

Endometr

iosis

(OMA)

n=105

(57.7%)

Deep-

inltrating

Endometr

iosis (DIE)

n=40

(21.85%)

OMA +

DIE

n=38

(20.76)

P-Value

Endometriosis Phenotypes

OMA 4/105

(2.85%)

1/40

(2.5%)

2/38

(5.2%)

0.677

DIE 25/105

(23.80%)

6/40

(15%)

8/38(21.0

0.254

Both OMA

and DIE

16/105

(15.23%)

5/40

(12.5%)

4/38

(10.52%)

0.486

DISCUSSION

The present study was conducted on patients suering

from adenomyosis and uterine broids with

endometriosis for the management of infertility. Data

showed the coexistence of broids and adenomyosis in

patients older than 32. TVS imaging is a reasonably

accessible imaging modality. It helped enhance the

patient management of endometriosis.11 Similar to the

previous ndings, it was found that the frequency of

adenomyosis was 21.85% in patients with pelvic

endometriosis.3,12 Adenomyosis, uterine broids, and

endometriosis can all have varying eects on fertility.

Infertility linked to endometriosis is associated with

ovarian damage, pelvic cavity alteration from

inammation and adhesions, pelvic architectural

distortion, inammatory peritoneal uid alterations,

and changed endometrium.13 Women who have

endometriosis are at high risk of infertility because of

this disease.14 Adenomyosis can result in infertility

through aberrant uterine contractility, abnormal

myometrial activity, and a disturbed endometrial milieu

with altered expression of implantation factors.16

Uterine broids also cause infertility in women.17,18 Our

results present the signicant importance of the US

assessment in evaluating endometriosis, adenomyosis,

and uterine broids for better patient management. This

is essential in the infertility clinic, where a

comprehensive evaluation determines the best course of

action for conception and a successful pregnancy

outcome. Furthermore, the presence of endometriosis

and uterine problems may have signicant eects on

patient care and the ensuing medical and surgical

therapy.TVUS is required in the therapy of infertility to

select the appropriate and patient-centered treatment,

taking into account uterine diseases, endometriosis, and

other gynecological comorbidities. Considering many

factors, such as the ovarian reserve, broids distorting

the uterine cavity, the endometriosis phenotype and

pelvic anatomy, and many more, these diagnostic

approaches assist the doctor in selecting appropriate

treatment for the patients. Patients’ personalized

treatment is essential, and patients with endometriosis

receive dierent therapy.

LIMITATIONS

The study has several limitations, including its cross-

sectional design, which prevents establishing causal

relationships. The sample size of 250 patients may not

be representative, and reliance on ultrasound for

diagnosis could underreport conditions due to its lower

sensitivity. The lack of histopathological conrmation,

failure to account for confounding factors, and a single-

center design limit the study's accuracy and

generalizability. Additionally, the absence of detailed

fertility data and long-term follow-up restricts

understanding of the impact on reproductive health.

CONCLUSIONS

Endometriosis is one of the foremost causes of

infertility. Our study ndings can help assess the

patients with endometriosis, which will help in a

multidisciplinary approach, better treatments, and

ongoing support to relieve symptoms, maximize

fertility outcomes, and enhance the patient's well-being.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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CONTRIBUTORS

1. Hina Niaz - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Supervision, Final Approval

2. Dure Nayab – Data Acquisition; Data Analysis/Interpretation

3. Asaf Alam Khan - Data Analysis/Interpretation

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Understanding the Coexistence of Adenomyosis andUterine Fibroids