GPAtlas🧭 When to suspect
Suspect adenomyosis in women of reproductive age presenting with heavy menstrual bleeding (HMB) and/or dysmenorrhoea, particularly when the uterus feels bulky and tender. Adenomyosis is a benign condition in which endometrial-like glands and stroma are present within the myometrium (the muscle of the womb).
It may also cause dyspareunia, chronic pelvic pain, subfertility, and adverse pregnancy outcomes such as miscarriage and preterm birth. It frequently coexists with fibroids and endometriosis. Adenomyosis affects as many as 1 in 10 women of reproductive age (and 20–35% of women attending specialist gynaecology clinics on imaging), but about a third are asymptomatic. Symptoms typically settle after the menopause.
The key clinical skill is to recognise the pattern, image with transvaginal ultrasound, distinguish it from fibroids, and tailor treatment to symptoms and fertility intent – while never missing endometrial pathology behind abnormal bleeding.
| Adenomyosis | Uterine fibroids | Endometriosis |
|---|---|---|
|
• Diffusely bulky, globular, symmetrical, tender uterus • Heavy and painful periods; pain often diffuse/cramping • TVS: globular uterus, asymmetrical myometrial thickening, myometrial cysts |
• Firm, often asymmetrical/lumpy, usually non-tender enlargement • Heavy periods ± pressure/bulk symptoms; pain less prominent • TVS: discrete, well-defined myometrial masses |
• Uterus often normal size; may have fixed/tender adnexa or nodularity • Cyclical pelvic pain, deep dyspareunia, dyschezia • TVS may be normal; assess per the endometriosis pathway |
Source: NICE NG88
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