History and exam
Key diagnostic factors
common
dysmenorrhea
Dysmenorrhea is present in almost all symptomatic women (approximately 95%).[17]
It is important to obtain a full menstrual history, including age of menarche, menstrual bleeding pattern, severity (e.g., clots or flooding), and pain associated with bleeding.[50]
Dysmenorrhea, dyspareunia, and chronic pelvic pain are cardinal symptoms of both adenomyosis and endometriosis.[11] In one case-control study comparing symptoms among 255 women undergoing hysterectomy, pain symptoms predicted a higher likelihood of both adenomyosis and fibroids rather than fibroids alone being found on histology.[41]
menorrhagia
Menorrhagia is a common presenting symptom of adenomyosis and is present in approximately 65% of symptomatic patients.[17]
Menorrhagia is defined based on the patient's perception of excessive blood loss that is heavy enough to interfere with quality of life (physically, socially, emotionally, and/or materially).[3][49][50] Menstruation lasting >8 days is also defined as abnormal by the International Federation of Gynecology and Obstetrics (FIGO).[49]
It is important to obtain a full menstrual history, including age of menarche, menstrual bleeding pattern, severity (e.g., clots or flooding), and pain associated with bleeding.[50]
enlarged, globular, tender uterus
dyspareunia
Dyspareunia is a common presenting symptom of adenomyosis and is reported by approximately 60% of symptomatic patients.[17]
Dysmenorrhea, dyspareunia, and chronic pelvic pain are cardinal symptoms of both adenomyosis and endometriosis.[11] In one case-control study comparing symptoms among 255 women undergoing hysterectomy, pain symptoms predicted a higher likelihood of both adenomyosis and fibroids rather than fibroids alone being found on histology.[41]
chronic pelvic pain
Chronic pelvic pain is reported by 50% to 90% of women with adenomyosis.[2][11]
Dysmenorrhea, dyspareunia, and chronic pelvic pain are cardinal symptoms of both adenomyosis and endometriosis.[11] In one case-control study comparing symptoms among 255 women undergoing hysterectomy, pain symptoms predicted a higher likelihood of both adenomyosis and fibroids rather than fibroids alone being found on histology.[41]
Other diagnostic factors
uncommon
subfertility or adverse pregnancy outcomes
Adenomyosis may be diagnosed incidentally in women with a history of subfertility or adverse pregnancy outcomes. In one study of 1015 patients undergoing assisted reproductive methods following a history of infertility, pregnancy loss, or recurrent implantation failure, 24.4% were found to have sonographic signs of adenomyosis.[54]
One systematic review and meta-analysis found that adenomyosis was associated with a higher risk of adverse pregnancy outcomes including preterm delivery (odds ratio [OR] 2.65), preeclampsia (OR 4.32), pregnancy-induced hypertension (OR 3.11), cesarean section (OR 2.48), fetal malpresentation (OR 3.05), small for gestational age (OR 2.86), intrauterine growth restriction (OR 3.4), postpartum hemorrhage (OR 2.90), and placental malposition (OR 4.94).[55]
One literature review and meta-analysis assessing IVF/intracytoplasmic sperm injection (ICSI) outcomes found that women with adenomyosis had a reduced likelihood of clinical pregnancy compared with women without adenomyosis (clinical pregnancy rate of 41% in women with adenomyosis vs. 50% in those without).[56] The same study found that miscarriage occurred in 32% of women with adenomyosis compared with 14% of those without adenomyosis.[56]
Ask any woman who has symptoms and/or signs of adenomyosis about any previous pregnancies and outcomes, as well as any history of miscarriage, ectopic pregnancy, pregnancy complications, and infertility (including assisted reproductive treatments and outcomes).
Risk factors
strong
reproductive age group
Adenomyosis is most commonly identified in women between age 35 and menopause; however, it can be found in women of all ages including adolescents.[10] In one study of 270 women ages 12-20 years referred to a gynecologic ultrasound unit, adenomyosis was diagnosed in 5% of adolescent patients, and up to 44% of these cases were associated with concomitant endometriosis.[35]
After menopause, estrogen deficiency may decrease symptoms and prevalence of adenomyosis.[12] In one study, premenopausal and perimenopausal women had an increased prevalence of surgically confirmed adenomyosis at baseline compared with postmenopausal women not using hormone therapy (prevalence odds ratio [POR] 4.72, 95% CI 3.22 to 6.91 and 3.40, 95% CI 2.10 to 5.51, respectively).[12] However, postmenopausal women who were using estrogen-only preparations, combined estrogen and progestin preparations, or a combination of both had a higher prevalence of adenomyosis compared with postmenopausal women who did not use hormone therapy (estrogen-only: POR 2.09, 95% CI 1.27 to 3.43; combined estrogen and progestin: POR 2.87, 95% CI 2.04 to 4.02; combination of both: POR 4.93, 95% CI 3.37 to 7.21).[12]
gravidity and parity
The process of trophoblast invasion into the inner myometrium during pregnancy has the potential to disrupt the border between the endometrium and myometrium, leading to an increased likelihood of adenomyosis.[36]
While some studies have reported an association between parity and adenomyosis in hysterectomy patients, results have been inconsistent.[37] One study of 985 women undergoing transvaginal ultrasound (TVUS) revealed a positive correlation between the number of pregnancies and the risk of adenomyosis compared with nulliparous women (1 pregnancy: odds ratio [OR] 1.83, 95% CI 1.09 to 3.06; 2 pregnancies: OR 2.46, 95% CI 1.44 to 4.30; 3-5 pregnancies: OR 2.66, 95% CI 1.62 to 4.28; ≥6 pregnancies: OR 4.90, 95% CI 2.57 to 9.35).[6]
early menarche
Early menarche results in prolonged exposure to estrogen and may serve as an indicator of disturbance in the developmental process of the reproductive system during early life.
In one large cohort study of 80,000 women, menarche at or before age 10 was associated with a 59% increase in prevalence of surgically confirmed adenomyosis compared with a later age of menarche (prevalence odds ratio [POR] 1.59, 95% CI 1.26 to 2.01).[12]
endometriosis
endometrial hyperplasia
Correlation between endometrial hyperplasia and adenomyosis has been found to be strong in two studies.[4][39]
In one study of 707 women who underwent hysterectomy, the estimated odds ratio (OR) for adenomyosis was 2.5 (95% CI 1.2 to 5.2) in women with endometrial hyperplasia compared with those without.[39] Another study of 549 women who underwent hysterectomy found that the presence of endometrial hyperplasia at the time of hysterectomy was the only significant variable associated with adenomyosis (OR 3.0, 95% CI 1.2 to 8.3).[4]
weak
black or Hispanic ethnicity
short menstrual cycle
The relationship between menstrual cycle length and the risk of adenomyosis remains inconclusive, although some studies suggest that shorter menstrual cycles may be associated with a higher risk.[12][39][43]
One study found that individuals with menstrual cycles of 24 days or less had a higher prevalence of adenomyosis compared with those with 27- to 28-day cycles (odds ratio [OR] 1.46, 95% CI 1.13 to 1.89).[12] Another study found no association between irregular menstrual cycles and adenomyosis.[43]
spontaneous and induced abortion
Spontaneous and induced abortions may cause disruption of the endometrial-myometrial border if the pregnancy lasts longer than 9 weeks, due to peak trophoblast invasion during this time.[39][40]
Of studies that analyzed induced abortion, to date all except one have reported a significant and positive link with adenomyosis.[5][39][40][43]
Two studies have reported a link between spontaneous abortion and the prevalence of adenomyosis (both studies reported odds ratio [OR] 1.6, 95% CI 1.0 to 2.4).[39][40] However, one study found no association.[43]
past uterine surgery
Data from two studies conducted among patients who underwent hysterectomy suggested a positive association between uterine surgery and histologically confirmed adenomyosis.[43][44] One study defined "any uterine surgery" as a history of one or more of cesarean delivery, myomectomy, endometrial ablation, dilatation and evacuation, and dilatation and curettage.[44] The other study evaluated "previous abdominal surgery," but types of surgeries were not specified.[43]
As cesarean delivery entails both surgical interference with the endometrial-myometrial border and trophoblast invasion associated with pregnancy, it is pathophysiologically plausible that undergoing a cesarean section may increase the risk of adenomyosis. One study did suggest a modest association.[5] However, most other studies have found no significant association.[4][43][45]
use of tamoxifen
obesity
Evidence is inconsistent on whether obesity is associated with a higher risk of adenomyosis.
Two studies that utilized body mass index (BMI) data collected prior to the diagnosis of adenomyosis found that women with a BMI ≥30 kg/m² had a higher risk of developing adenomyosis compared with those with BMI <25 kg/m² (odds ratio [OR] ranging from 1.4 to 3.8).[12][45]
However, in studies where BMI was measured at the time of hysterectomy-based histologic diagnosis, the reported findings were mixed, with some studies reporting a positive association with higher BMI while others found an inverse association or no association at all.[43][45][48]
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