Endometriosis programme · Adenomyosis

Adenomyosis — a reference for patients and referring clinicians

Adenomyosis is the presence of endometrial-type tissue within the muscular wall of the uterus (the myometrium). It is a distinct condition from endometriosis, although the two can coexist and share some symptoms. At Balaji Horizon Women’s Hospital, adenomyosis is evaluated and treated within the same programme led by Dr. Priyadatt Patel — Senior Gynecologist, Advanced Laparoscopic Surgeon, and IVF & Endometriosis Programme Lead — with formal training at the Kiel School of Gynaecological Endoscopy (Germany) and an ESGE/CICE Diploma in Endoscopic Surgery (France). The programme has handled 500+ endometriosis and adenomyosis cases and 3,000+ advanced laparoscopic procedures across 13+ years, with imaging performed to MUSA consensus standards. This page describes how adenomyosis is recognised, diagnosed, and treated — with a fertility-preserving philosophy throughout.

What adenomyosis is — and how it differs from endometriosis

Adenomyosis is endometrial-like glands and stroma found within the muscle of the uterus. Endometriosis, by contrast, is endometrial-like tissue found outside the uterus — on the ovaries, peritoneum, bowel, bladder, and other pelvic structures. They are separate diseases:

• Adenomyosis — lives inside the uterine wall; makes the uterus bulky, tender, and dysfunctional
• Endometriosis — lives outside the uterus; causes pelvic adhesions, ovarian cysts, and deep nodules

The two conditions overlap in symptoms and frequently coexist. Around 20–25 per cent of women with endometriosis also have adenomyosis; conversely, many adenomyosis patients also have surface endometriosis. Diagnosing one without checking for the other is incomplete.

Why adenomyosis is often missed

Adenomyosis is underdiagnosed because:

• Symptoms (heavy painful periods, chronic pelvic pain, infertility) overlap with fibroids, endometriosis, and ordinary dysmenorrhoea
• Historically the diagnosis required histology after hysterectomy — meaning younger patients with intact uteri were rarely diagnosed
• Standard pelvic ultrasound without the MUSA criteria framework misses subtle imaging features
• The bulky tender uterus on examination is often attributed to fibroids alone
• Heavy periods are normalised by patients and by clinicians

Modern imaging has changed this. MUSA-criteria transvaginal ultrasound and dedicated pelvic MRI now allow accurate diagnosis in patients who keep their uterus — including patients planning fertility.

Symptoms to recognise

• Heavy menstrual bleeding — often described as flooding, with large clots
• Severe dysmenorrhoea — cramping pain that builds in the days before menses and continues through the period
• Chronic pelvic pain — non-cyclical pelvic discomfort, often with a dragging or pressure quality
• Deep dyspareunia — pain on deep penetration
• Infertility or subfertility — particularly difficulty with implantation and higher early pregnancy loss
• Bulky tender uterus — on examination, the uterus feels enlarged and globular, often tender
• Anaemia — secondary to chronic heavy bleeding

Severity varies widely. Some patients are asymptomatic and the diagnosis is incidental on imaging done for other reasons. Others have life-limiting symptoms that have been mis-attributed to fibroids or to ordinary period pain for years.

Diagnostic approach

The diagnostic pathway is non-invasive, paced, and structured:

1. Structured history — bleeding pattern, pain pattern, fertility goals, prior pregnancies, prior surgery, family history
2. Pelvic examination — assessing uterine size, tenderness, mobility
3. Transvaginal ultrasound following MUSA consensus criteria — the structured imaging framework that documents asymmetric myometrial thickening, myometrial cysts, hyperechoic islands, sub-endometrial echogenic lines and buds, irregular junctional zone, fan-shaped shadowing, and translesional vascularity. Each feature is recorded explicitly.
4. MRI of the pelvis — for complex cases, severe adenomyosis with suspected deep endometriosis, or surgical planning. MRI quantifies the junctional zone thickness and visualises focal versus diffuse disease.
5. Full blood count and ferritin — to assess and correct anaemia
6. Thyroid, prolactin, and other endocrine work — where bleeding pattern suggests an additional cause
7. Endometrial biopsy — for patients over 45, post-menopausal bleeding, or where imaging suggests endometrial pathology

All diagnostic ultrasound at Balaji Horizon is performed following the MUSA and ISUOG consensus frameworks — Dr. Patel is formally trained in structured systematic imaging, which substantially out-performs generic pelvic ultrasound for detecting both adenomyosis and any coexistent endometriosis.

Treatment principles — medical first, fertility-aware

Treatment is individualised by symptom burden, fertility goals, age, and severity of disease. A great deal of adenomyosis is treated successfully without surgery.

• Levonorgestrel intrauterine system (LNG-IUS) — first-line for many patients. Reduces bleeding substantially, often eliminates dysmenorrhoea, preserves fertility for later. Particularly effective for diffuse adenomyosis.
• Combined hormonal contraception — cyclical or continuous; useful in patients who tolerate it and do not need contraception alternatives
• Progestogens — dienogest is well-tolerated for long-term use
• GnRH analogues with add-back — for severe disease, pre-operative shrinkage, or as a bridge to IVF
• Tranexamic acid and NSAIDs — for bleeding and pain on a cycle-by-cycle basis
• Surgical adenomyomectomy — localised excision of focal adenomyosis in selected patients who want to retain fertility. Technically demanding; preserves the uterus but recurrence is possible.
• Hysterectomy — the definitive treatment when fertility is complete and conservative options have not relieved symptoms. Approached only after structured counselling.
• Uterine artery embolisation — selected use in symptomatic patients who decline hysterectomy

The institutional position is that hysterectomy is not the default answer for adenomyosis in a patient who has not completed her family. Medical therapy, the LNG-IUS, and surgical preservation options are explored first.

Adenomyosis and IVF — what the evidence shows

Adenomyosis is associated with reduced IVF implantation rates and higher early pregnancy loss. The biological reasons include altered junctional-zone contractility, impaired uterine receptivity, and a pro-inflammatory endometrial environment. The clinical implications:

• Adenomyosis should be looked for in any patient presenting for IVF with unexplained recurrent implantation failure
• MRI may be appropriate in selected pre-IVF evaluation where ultrasound is equivocal
• GnRH agonist pre-treatment for 2–3 months before stimulation has shown improved implantation and clinical pregnancy rates in patients with significant adenomyosis
• Where coexistent endometriosis is identified, the surgery-versus-IVF decision is made jointly with the endometriosis surgical pathway
• The pathway is detailed in endometriosis and IVF integration and recurrent implantation failure

How Dr. Priyadatt Patel and the Balaji Horizon team approach adenomyosis

The institutional approach to adenomyosis rests on four anchors:

1. Structured MUSA-criteria imaging. Dr. Patel personally performs adenomyosis imaging in complex cases. The diagnosis is reported with all MUSA features documented explicitly — not as a single “adenomyosis suspected” phrase. This precision allows medical-vs-surgical decision-making to be based on the actual disease pattern, not a vague impression.
2. Medical-first, fertility-preserving philosophy. The LNG-IUS is offered as first-line for the large majority of symptomatic patients who do not want immediate surgery. Most respond well. Hysterectomy is the contingency, not the default. This stance reflects the long-term institutional position on uterine preservation wherever clinically reasonable.
3. Coordinated check for coexistent endometriosis. Every adenomyosis patient is also assessed for endometriosis with the same ISUOG IDEA-protocol scan, because the two so often coexist and the management changes meaningfully when both are present.
4. Integration with IVF when fertility is the goal. Adenomyosis affects IVF outcomes; the planning is done jointly with the fertility programme rather than referred sequentially. GnRH agonist pre-treatment is considered selectively per the evidence.

Dr. Patel’s broader training — Kiel (Germany), ESGE/CICE Diploma (France), ISUOG IDEA and MUSA imaging, four postgraduate gold medals — sits behind every adenomyosis consultation at the centre. The full credentials are at the Dr. Priyadatt Patel profile.

Long-term care

Adenomyosis is a long-term condition. After initial treatment, structured follow-up is offered at 3 months, 6 months, then annually. The LNG-IUS is replaced at 5–7 year intervals per current evidence. Iron status is monitored periodically. Where symptoms re-emerge or worsen, the medical regimen is re-evaluated before any surgical escalation. Adenomyosis tends to regress after menopause; in patients close to the menopausal transition, watchful waiting with symptom control can be a sound long-term plan.

When to seek a specialist opinion

• Heavy menstrual bleeding causing anaemia or interfering with daily life
• Severe period pain that does not respond to standard analgesia or hormonal therapy
• Chronic pelvic pain with a bulky tender uterus on examination
• A scan report mentioning adenomyosis, myometrial cysts, asymmetric uterine wall, or a thickened junctional zone
• Subfertility or recurrent implantation failure with imaging features of adenomyosis
• Considering pregnancy in a patient with known adenomyosis
• Looking for a structured second opinion before considering hysterectomy

Guidelines we follow on this topic

• ESHRE Endometriosis Guideline 2022 (adenomyosis section)
• MUSA (Morphological Uterus Sonographic Assessment) Consensus 2015 + 2022 update
• FIGO classification of uterine pathology
• NICE Heavy Menstrual Bleeding (NG88)
• RCOG Green-top guidance on adenomyosis and infertility
• International consensus on uterine-sparing treatment of adenomyosis

Related reading

• Endometriosis programme overview
• Deep infiltrating endometriosis (DIE)
• Imaging for endometriosis
• Endometriosis and fertility
• Endometriosis and IVF integration
• Recurrent implantation failure
• Fibroids (differential diagnosis)

Dr. Priyadatt Patel

Senior Gynecologist · Advanced Laparoscopic Surgeon · IVF and Endometriosis Programme Lead

MS OBGyn · Pregnancy Care · Advanced Gynaecological Ultrasound · Fertility Preservation

ESHRE / ESGE / AAGL / ASRM guideline-aligned practice. 3D Karl Storz precision technique. Fertility-preservation-first philosophy. Evidence-based decisions, honest counselling, long-term outcomes orientation.