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Cycles and Pelvic Health

Adenomyosis: Reading Pain, Bleeding and Imaging as One Clinical Picture

10 min readEvidence synthesis
Read the evidence

The question in focus

A guideline-based explanation of adenomyosis diagnosis, imaging, fertility questions and individualized treatment, including important evidence gaps.

Evidence at a glance

75% to 88%

reported sensitivity range for transvaginal ultrasound in studies summarized by a 2023 review

Specificity ranged from 67% to 93% across cited studies. Performance depends on criteria, operator expertise, disease pattern and reference standard, so imaging must be interpreted with symptoms and examination. [3]

Adenomyosis: An Updated Review on Diagnosis and Classification

What adenomyosis is, and what it is not

Adenomyosis describes endometrial-type glands and stroma within the uterine muscle, with surrounding muscle change. It is distinct from endometriosis, where endometrial-like tissue is found outside the uterus, although the conditions can coexist. Fibroids can also coexist. Similar symptoms mean a label should follow a structured assessment rather than one symptom alone. [1]

Historically, definitive diagnosis relied on examination of a uterus after hysterectomy. Modern transvaginal ultrasound and magnetic resonance imaging can support a clinical diagnosis without removing the uterus. [3] This shift matters because people can seek symptom control or fertility-preserving care without first accepting definitive surgery.

  • Common concerns include heavy bleeding and painful periods.
  • Some people report pain during sex or chronic pelvic pain.
  • Adenomyosis may be focal or diffuse.
  • Symptoms do not reliably show disease extent.

The history should connect bleeding, pain and life impact

NICE defines heavy menstrual bleeding by its impact on quality of life rather than a single measured blood-loss threshold. Assessment should cover bleeding pattern, pain, pressure, bleeding between periods, pregnancy goals, contraception, prior treatment and consequences such as fatigue. A full blood count is recommended for all women presenting with heavy menstrual bleeding. [2]

Red flags and alternative diagnoses still require attention. Pregnancy-related bleeding, infection, endometrial pathology, endometriosis, fibroids and bleeding disorders may need different investigations. A tender or bulky uterus can raise suspicion, but a normal examination does not exclude adenomyosis. The purpose is to build a differential diagnosis, not force every symptom into one explanation.

  • Document cycle timing and bleeding between periods.
  • Ask about bowel, bladder and sexual pain.
  • Assess anemia symptoms and functional disruption.
  • Record fertility priorities before choosing treatment.

Ultrasound is usually the first imaging step

For heavy bleeding with significant dysmenorrhea or a bulky, tender uterus, NICE recommends transvaginal ultrasound in preference to transabdominal ultrasound or MRI. [2] Ultrasound features can include an asymmetrical myometrium, myometrial cysts, fan-shaped shadowing, echogenic islands and changes at the junction between endometrium and myometrium. No single sign should be read in isolation.

MRI can help when ultrasound is inconclusive, not acceptable, technically limited or when detailed mapping would change a procedure. Proposed imaging classifications differ, and the relationship between an imaging phenotype, symptoms and treatment response is not yet fully standardized. [5] Reports are most useful when they describe location, extent, coexisting fibroids or endometriosis and diagnostic confidence.

  • Use experienced pelvic imaging where possible.
  • Ask whether findings explain the presenting symptoms.
  • Describe coexisting uterine and extrauterine disease.
  • Avoid treating an incidental image instead of the person.

Fertility evidence needs careful language

Adenomyosis has been associated in observational research with infertility, miscarriage and adverse pregnancy outcomes, but age, endometriosis, fibroids and selection into fertility clinics can confound estimates. The 2023 guideline includes reproductive outcomes as an important domain while recognizing that evidence for many fertility-directed interventions is limited. [1]

A fertility plan should consider age, ovarian reserve where clinically indicated, duration of trying, semen factors, tubal status, symptoms and imaging. Treatment intended to suppress bleeding or pain may also suppress ovulation temporarily. Surgery can affect the uterine wall. Decisions should therefore be coordinated between gynecology and reproductive medicine when pregnancy is a near-term goal.

  • Clarify whether pregnancy is desired now, later or not at all.
  • Discuss time cost as well as procedural risk.
  • Avoid promising that treating imaging findings restores fertility.
  • Plan obstetric follow-up based on the full clinical history.

Treatment is chosen by goal, not by a universal ladder

Options include nonsteroidal anti-inflammatory drugs for pain, tranexamic acid for bleeding, combined hormonal contraception, progestins, a levonorgestrel-releasing intrauterine system and gonadotropin-releasing hormone therapies in selected circumstances. The Canadian guideline also discusses uterine artery embolization, conservative surgery and hysterectomy. [1] Evidence strength and suitability vary by symptom, uterine anatomy and reproductive goal.

NICE recommends considering a levonorgestrel intrauterine system first for heavy bleeding with suspected or diagnosed adenomyosis when appropriate. [2] Hysterectomy is definitive for uterine adenomyosis but ends the ability to carry a pregnancy and has surgical risks. Uterine-sparing procedures should include candid discussion of recurrence, reintervention and uncertain reproductive outcomes.

  • Define the primary goal: bleeding, pain, fertility or several.
  • Review contraindications and desired contraception.
  • Agree how response will be measured.
  • Reassess the diagnosis when treatment repeatedly fails.

Where the evidence remains incomplete

Adenomyosis studies use varying imaging definitions, symptom measures and follow-up. Medical therapy is often extrapolated from endometriosis or heavy-bleeding evidence, and comparative trials are limited. A 2023 review describes promise for several therapies but emphasizes the need for disease-specific evidence and standardized guidance. [6]

Good care can still be rigorous. It should name uncertainty, use validated measures where available, check blood counts when bleeding is heavy, account for coexisting conditions and revisit goals over time. A documented baseline of bleeding, pain, daily function and reproductive priorities makes treatment response more interpretable than an image change alone.

  • Imaging criteria are not fully harmonized.
  • Long-term comparative treatment data are limited.
  • Fertility outcomes are vulnerable to confounding.
  • Uterine-sparing procedure evidence varies by technique.

What the evidence cannot yet answer

  • Published diagnostic accuracy varies with reference standard, operator expertise and patient selection.
  • Many treatment studies are observational, small or use inconsistent definitions of response.
  • Adenomyosis often coexists with endometriosis or fibroids, making symptom attribution difficult.
  • Evidence does not support predicting an individual's fertility outcome from one imaging finding.

Questions worth taking into care

  1. Which findings support adenomyosis, and what alternatives remain possible?
  2. Do I need a full blood count or evaluation for iron deficiency?
  3. Would MRI change the treatment decision?
  4. How does each option affect contraception and future pregnancy plans?
  5. What outcome and review interval will define success?

Source record

Evidence used in this review

Sources were selected for clinical authority, methodological relevance and traceability. Links open the original guidance, public-health record or research publication.

  1. [1]
    Guideline No. 437: Diagnosis and Management of Adenomyosis

    Society of Obstetricians and Gynaecologists of Canada · 2023

  2. [2]
    Heavy Menstrual Bleeding: Assessment and Management

    National Institute for Health and Care Excellence · 2021

  3. [3]
  4. [4]
  5. [5]
    MRI of Adenomyosis: Where Are We Today?

    Current Obstetrics and Gynecology Reports · 2022

  6. [6]
Editorial standard

This evidence synthesis is for general information. It does not diagnose a condition or replace care from a qualified health professional. Treatment choices depend on individual history, examination, local guidance and informed preference. Emergency or rapidly worsening symptoms need urgent local medical assessment.