In this episode, I’m shining a spotlight on adenomyosis: a condition that’s often misunderstood and overlooked, yet can have a profound impact on fertility and overall uterine health. I’m joined by Dr. Armando Hernandez-Rey, a board-certified reproductive endocrinologist and founder of Conceptions Florida, who is at the forefront of treating complex reproductive health issues, including adenomyosis, endometriosis, and recurrent pregnancy loss.
Together, we dive deep into what adenomyosis is, how it differs from endometriosis, why it’s so frequently undiagnosed, and what it means for those struggling with infertility or recurrent pregnancy loss. Dr. Hernandez-Rey shares his expertise on diagnosis, treatment options (including the latest in minimally invasive therapies) and how patients can best advocate for themselves. Whether you’re newly diagnosed or searching for answers, this conversation is packed with insights to empower you on your fertility journey.
In this episode we cover:
- The difference between adenomyosis and endometriosis, and why that distinction matters
- Why adenomyosis is often missed or misdiagnosed in fertility workups
- The impact of adenomyosis on implantation, pregnancy outcomes, and miscarriage risk
- Diagnostic tools: ultrasound vs. MRI and what to ask your doctor
- Treatment options, including hormonal therapies and emerging minimally invasive procedures like radiofrequency ablation
- How to advocate for yourself and what questions to ask your fertility specialist
- Real-world outcomes and statistics from Dr. Hernandez-Rey’s clinical experience
Resources:
Dr. Armando Hernandez-Rey’s practice: Conceptions Florida
Find Dr. Aimee’s Fertility Essentials & Supplements
Full Transcript:
Dr. Aimee: Today, we’re diving into a topic that deserves much more attention; adenomyosis. If you’ve ever been told that you have just had bad periods or you’re struggling with infertility without clear answers, this episode is for you. Adenomyosis affects up to one in ten women, yet it’s often overlooked and misdiagnosed, despite its significant impact on fertility, miscarriage risk, and overall uterine health.
The title of today’s show is “It’s Not Just Bad Periods: What You Need to Know About Adenomyosis and Fertility.”
Joining me today is a true expert in his field, Dr. Armando Hernandez-Rey. He’s a board-certified reproductive endocrinologist and the founder of Conceptions Florida. As one of only two fertility specialists in Miami offering robotic surgery, he specializes in treating complex reproductive health conditions like endometriosis, recurrent pregnancy loss, and of course, adenomyosis.
Dr. Hernandez-Rey, welcome to the show.
Dr. Armando Hernandez-Rey: Thank you, Aimee. It’s great to be here.
Dr. Aimee: Let’s dive into the questions. You’re known for being at the forefront of fertility care, including the use of robotic surgery. What inspired you to pursue this specialized path and how has it shaped your approach to treating conditions like adenomyosis?
Dr. Hernandez-Rey: I went into medical school to be an orthopedic surgeon, interestingly enough, and meandered over to the world of OBGYN, thinking that I was going to be a GYN oncologist, and I just fell in love with the whole subspecialty of infertility and reproductive endocrinology. I’ve always had a particular interest for the surgical route. I immediately fell in love with the tubal reanastomosis and the delicate microsurgery. I think it was my first interest, where my interest began with infertility, and then it’s not hard to just fall in love with the specialty. It’s so rewarding. It’s so cutting-edge, technologically-driven, and here I am.
Dr. Aimee: I want to talk a little bit more about adenomyosis and endometriosis. They’re often discussed together, but they’re very different. Can you break down what adenomyosis is and how it’s different from endometriosis, and why this distinction is so important for both diagnosis and treatment?
Dr. Hernandez-Rey: Sure. Endometriosis is basically a disease process, the tissue that women expulse every month with their menses makes its way retrograde through the fallopian tubes and implants in different areas, causing a significant amount of inflammation.
There are multiple theories, as you know, as to the genesis of endometriosis. The one that’s most prevailing or makes the most sense is in fact that retrograde expulsion. Interestingly enough, we know that happens in all women, but there are just some women that are more susceptible than others. Essentially, a dysfunction at the level of the endometrium that somehow initiates through the fallopian tubes. I think nobody really knows for sure, but essentially that’s what it means. Over time, it’s essentially increasing the level of the inflammatory response in the pelvis. There’s multiple organ systems, the juxtaposition between tube and ovaries, extremely important. The infiltration into the ovary itself as it makes its way in the form of an endometrioma, destroys the essential matrix of the egg and its capacity for ovulation and fertilization.
Then not to mention the quality of life aspects that are significantly impacted in a majority of women, not all women, but in a majority of women who suffer from endometriosis. The symptoms, as we all know, do not necessarily correlate with the extent of disease. Someone can have stage four endometriosis that goes relatively asymptomatic and a stage one that is doubled over in the fetal position for three to five days, if not longer, throughout the cycle.
What we know about endometriosis and adenomyosis and why it’s spoken about often in the same sentence is because these are disease processes, whether related or not related, that evolve over time. It’s very odd, although not impossible, to see somebody with adenomyosis that early in the stages of their reproductive lifespan, and yet much more common to see it at the later stages, which is one of the reasons I’m sure we’ll talk about why we’re seeing it so often now.
With adenomyosis, to go a little bit further, to answer your question fully and to separate it out from endometriosis, adenomyosis is basically the infiltration of that same endometrial tissue or that penetration and invagination of that tissue into the muscle of the uterus. It creates a bulky uterus, dysregulates the normal menstrual flow, causing irregular bleeding and painful bleeding. Also, as it expands, it becomes bigger, causing the symptom complex that are associated with painful sex, chronic pelvic pain, and dysmenorrhea or painful periods as well.
Dr. Aimee: It’s not that uncommon, but why is it so frequently undiagnosed?
Dr. Hernandez-Rey: The gold standard is MRI because that gives us an opportunity to examine the junctional zone, which can’t otherwise be visualized with transvaginal ultrasonography, number one. Certainly, to the seasoned clinician, when you see an advanced case of adenomyosis, you only have to just put the probe in and take a look and you’ll know that there is some degree of adenomyosis. It presents in many different ways, but you see an enlarged uterus, enlarged uterine volume, and ground glass appearance within the matrix of the myometrium itself, and sometimes you can see some glandular tissue, which is sometimes difficult to differentiate between a degenerated myoma versus an adenomyotic gland within the myometrium itself.
Dr. Aimee: What’s so frustrating for me, and I’m sure you get these cases too, patients have gone through years of treatment, many failed transfers, and their doctors aren’t recognizing the impact that adenomyosis has. Let’s talk a little bit about that. What are the impacts that adenomyosis has on implantation and pregnancy outcomes?
Dr. Hernandez-Rey: The environment within the endometrium that is absolutely critical for implantation to occur, you see a complete absence or increase in MMP 1 and 2, matrix metalloproteinases that are essential for implantation to occur, you see an increase in cytokines, which creates an inflammatory response, you see a picture of chronic endometritis, which is not an infection but an inflammatory response that occurs, and that completely distorts the capacity for the nidation of the embryo to make its way into the first layers of the endometrium and begin the trophoblastic or the blastation that needs to occur for implantation and growth.
Dr. Aimee: For those who are listening, if you’ve received this diagnosis and your doctor is saying it’s no big deal and it doesn’t impact pregnancy or implantation, that’s just not true. Wouldn’t you say?
Dr. Hernandez-Rey: Absolutely. The reason why this is at the forefront of our discussions now is because it’s having a significant impact on implantation. We’re seeing older women who have certain risk factors, whether it’s multiple losses that require instrumentation, endometriosis, fibroid surgeries, etcetera. These are all known factors that are associated with adenomyosis.
As we know, women are waiting longer. Sometimes women have to consider the option of egg donation. We know that the components of a pregnancy – not to simplify it, but for our audience – is egg, sperm, and embryo. That’s one unit. The external environment, whether it’s because of obesity, diabetes, or some underlying comorbidities. Then finally, the uterus.
You’re presenting the best case scenario to these patients, young healthy women, who unfortunately are at the end of their reproductive lifespan and need to go to egg donation, and you’re thinking about the best case scenario. Then when you have the additional obstacle to deal with, which is adenomyosis, it’s very hard for these women to wrap their mind around this, “I’ve gone this far to do egg donation, and now I can’t even carry a pregnancy?” That’s very difficult, and certainly one of the challenges that fertility specialists face in today’s world.
Dr. Aimee: You mentioned when you do an ultrasound, you can tell if someone has adenomyosis.
Dr. Hernandez-Rey: Absolutely.
Dr. Aimee: In those patients, do you tend to still get an MRI, do you find that to be useful?
Dr. Hernandez-Rey: I think it’s very helpful to measure the extent of the adenomyosis. You can glean from the volume and the overall appearance of what it looks like, but I think it’s important to measure the junctional zone. If you’re going to treat it, whether it be hormonal therapy or surgical therapy, you want to have a starting point, a baseline to know whether you’re improving, staying the same, or getting worse, God forbid.
Dr. Aimee: Let’s talk about that. Let’s talk about how you approach treatment. Does the amount of adenomyosis impact the type of recommendations you make for a patient? I’m sure you get this question a lot. What about surgery, can’t I just do surgery for it?
Dr. Hernandez-Rey: It’s a very complex question, and one that I’m not sure we have all the answers for. Traditionally, back when you and I were fellows, we always just had Lupron to treat adenomyosis.
Dr. Aimee: Just so you know, I call it Devil Lupron.
Dr. Hernandez-Rey: It is Devil’s Lupron, absolutely. It makes sense. You’re suppressing the hypothalamic-pituitary-ovarian axis, decreasing the production of ovarian-produced steroids, estrogen essentially, and progesterone. Which is, by the way, how we treated endometriosis back in the day as well. In addition to surgery, many times, the post-op treatment was Lupron. By suppressing this hormonal milieu, we’re in theory reducing the stimulation to the uterus, to the lining, the endometrium, and hopefully reducing the volume in such a way. But I don’t know that we have any way of necessarily gauging it beyond just a decrease in the volume of the uterus, if it’s having an effect on receptivity or anything else. Although, as you put a patient post-treatment with hormonal therapy, whether it’s Lupron, or today I use Orilissa or a GnRH antagonist instead of an agonist like Lupron is, we can see how well the patients do in terms of lining development, endometrial development, the characteristics of the endometrium, whether it’s a trilaminar appearance or homogenous when you start the progesterone, the thickness of the lining itself is also extremely important.
We’re just playing detective here, we’re trying to glean as much information as we can, which is why adenomyosis has become so important. As practitioners, we take pride in what we do, we want to be able to offer the best possible success rates for our patients. When you’ve eliminated the egg or sperm in the cases that I mentioned, you want to be able to do something as far as addressing the uterine component, which is just as important as all of the others.
Dr. Aimee: I’m glad you brought that up because I think so many patients don’t know that they can advocate for themselves and say things like, “Can you check the uterine volume,” to see how it has changed over time. That’s something that I do as well. When I make a plan with a patient who had adeno, and I also prefer Orilissa because it’s out of the system faster and I can adjust the dose if they don’t feel well on it, and you can measure the volume. Sometimes I bring them every 30 days, sometimes at the two-month mark, and sometimes I extend the treatment beyond two months, which I’m sure you do for some cases. I think it’s important to point out for our listeners that doctors like us, we are the detectives, we want to investigate, we want to make sure we’re doing the very best for our patients. I’m so glad you said that so that other people know that it’s okay to ask for that if your doctor is not offering you that.
Dr. Hernandez-Rey: Absolutely. You should always advocate for yourself.
Dr. Aimee: Yes. Getting a uterine volume check is really easy. It’s just a basic pelvic ultrasound, something that we could do in our sleep for you.
Dr. Hernandez-Rey: That’s right.
Dr. Aimee: I’ve been getting a lot of patients messaging me about ultrasound-guided focal destruction of adenomyosis tissue. This is an emerging therapy using radio frequency and microwave ablation, and it’s referred to as adeno-duo. I’m not sure I’m saying that right. Do you have any experience with this approach or know how it compares to traditional approaches?
Dr. Hernandez-Rey: I do have experience with this approach. This is a new term that they’ve put together. I have used this before, I’ve used this modality and this technology before in the way of a treatment or a technique that is called Acessa, a device that’s owned by Hologic that is laparoscopic. There’s also the opportunity to do hysteroscopic radio frequency ablation as well, which I actually like very much.
I’ve done 18 cases of radio frequency ablation. Certainly not the 131 that were used in that trial that recently came out. I’ve read the trial. I’ve read the results, and they’re certainly very promising. You’re talking about two very good surgeons who are leading the charge. I find the difficulties or the limitations are that it depends on the stage, like everything else. You want to treat stage one cancer before you want to treat stage four cancer, so it has to be early intervention. I have last-ditch efforts, to be honest with you, before having to move on to surrogacy. The majority of patients that I’ve treated with the Acessa device or the radio frequency ablation are the stage threes, the stage fours, very advanced, very large, greater than 200 cc uteruses that have come to me perhaps for a second opinion because they’ve failed multiple embryo transfers at an outside facility and now we’re stuck here trying to figure out what to do. Like ovarian cancer and the way we treat endometriosis, I think we just alluded to it, you do the debulking of the endometriosis and then instead of chemo, you’re using the Lupron, as we used to do before, and maybe the Orilissa, which we know in women who are trying to conceive, we should try to stay away from that. Surgery certainly doesn’t add any benefit to fertility, but it can have a significant impact or a one-two punch, as I just mentioned, in terms of quality of life.
With adenomyosis, minimally invasive or being conservative is best. Certainly, the treatment with surgery when all else fails can be a consideration. Because it’s laparoscopic and we see the combination of endometriosis and adenomyosis, sure, we do that, too. Sometimes there are so many adhesions that to even do the radio frequency ablation we have to take down adhesions, we have to take down the endometriosis in order to be able to get access to the bulk of the adenomyosis or the fibroids, which is how this therapy began first, which is radio frequency ablation reduced the volume of fibroids in order to reduce the volume of the uterus itself and decrease symptoms.
Dr. Aimee: In the patients that you’ve seen with a uterus that large who have done this treatment, have they been able to go on to have a healthy full-term pregnancy?
Dr. Hernandez-Rey: In our group of patients, I’ve looked at it before. I’ve done 18 cases of radio frequency ablation, but not necessarily all of them were for fertility. Of the 14 that came to us, we have six that have gotten pregnant, four that have delivered via C-section, no vaginal deliveries, one that had a miscarriage, and one that is an ongoing pregnancy in the second trimester.
Dr. Aimee: I think those are really good statistics. For those who are listening, I’ll make sure to have Dr. Hernandez-Rey’s information in our show notes so that you can reach out to him for a consultation for this procedure. I think there are so many doctors out there that discourage patients from seeking this kind of therapy because they’re nervous about what it means for pregnancy, but it’s nice to hear that you’ve had this experience that seems positive and promising.
For patients experiencing unexplained failed embryo transfers or recurrent pregnancy loss who suspect adenomyosis, how can they best advocate for themselves when seeking help from a specialist?
Dr. Hernandez-Rey: Ask questions. Definitely ask questions. I think that it’s important to be well informed. Patients say, “I’m so sorry, I looked at Google.” It’s important to have a framework to begin the discussion when this is something you don’t do for a living, just to have some information to discuss is important. You have to be an advocate for yourself. We as physicians should not get mired in the busyness of every patient, this is not cookie cutter medicine, and you have to address every patient individually. As women age, things are getting more complex when we thought they were going to get simpler and, unfortunately, that’s not the case.
Dr. Aimee: Those are all great tips. I think it’s also important to ask the right person questions. Sometimes patients seek out the opinion of their OBGYN who is very well intentioned, but that doctor doesn’t necessarily refer them to someone who is an expert like you. If you’re going to someone who isn’t used to making the diagnosis and isn’t experienced in helping women get pregnant with adenomyosis, they might not be the best person to ask because they might say that you don’t have it when you actually may have it.
Where can listeners learn more about your work and if they would like to connect with you and work with you?
Dr. Hernandez-Rey: My practice name is Conceptions Florida. We have a pretty active social media presence. You can Google ‘Conceptions Florida,’ and we have two offices in South Florida, we’re in Coral Gables at Merrick Park. They can find me just going online and putting in my name.
Dr. Aimee: Is there anything else you’d like to share with our audience, especially those who may be feeling overwhelmed or uncertain about their diagnosis?
Dr. Hernandez-Rey: I think that it’s extremely important, and I think you touched on this, to be the advocate. That’s very key. Adenomyosis is something that we’re just starting to understand more and more because it has become more prevalent in our population. Adenomyosis has been around forever. Just when women had five children and were symptomatic, the hysterectomy was the go-to route. Now these women are wanting to be pregnant and we’re having to deal with the adenomyosis, so we’re learning more.
Whether it’s adenomyosis, endometriosis, or any other diagnosis, please do not hesitate to ask. Don’t be afraid to ask the right questions, get informed, do your research. If you don’t like what the answer is, perhaps get a second opinion.
Dr. Aimee: I’m glad you said that about hysterectomy, because oftentimes I hear OBGYNs saying things like, “The only way I can diagnose this is if you have a hysterectomy,” and that’s not a nice thing to say to someone who is trying to have a baby and that’s just untrue. You can diagnose it with ultrasound and MRI.
Thank you, Dr. Hernandez-Rey, for joining us and helping to shed light on a condition that too often goes unrecognized. Your insights are truly invaluable and your dedication to patient-centered care is inspiring.
If you’ve found this episode helpful, please subscribe to The Egg Whisperer Show on YouTube and follow us on Spotify so you never miss a podcast episode. We have more insightful conversations coming your way to help you feel empowered and informed on your fertility journey. Until next time, I’m Dr. Aimee. Stay hopeful.
