Pathogenesis

The etiology of the adenomyosis is yet to be clearly elucidated. However, some theories have been postulated which include disruption of the boundary between the deepest level of the endometrium and the inner myometrium. This is the most commonly accepted theory

A second theory proposes an embryologic mechanism whereby pluripotent Mullerian stem cells undergo inappropriate differentiation leading to ectopic endometrial tissue

Risk factors

Risk factors for adenomyosis include conditions leading to increased estrogen exposure (increased parity, early menarche, short menstrual cycles, elevated body mass index, oral contraceptive pill use, tamoxifen use) and prior uterine surgery (dilation and curettage, cesarean section, myomectomy, etc.)

Clinical features

Patient may present with a history of chronic pelvic pain, abnormal uterine bleeding, dysmenorrhea and dyspareunia. Other features may include anaemia, a diffusely enlarged, tender and firm uterus and infertility. Some women may be asymptomatic.

Investigations

This may include use of modalities like transvaginal scan (TVS) and magnetic resonance imaging (MRI). Definitive diagnosis is by histology which reveals the presence of endometrial stroma and glandular tissue noted within myometrium. Full blood count with clinical suspicion for anaemia.

Treatment

Treatment options include medical and surgical options. The choice of treatment option depends on factors like age of the patient, symptomatology and desire for future fertility. 

Medical management involves the use of agents like non-steroidal anti-inflammatory drugs which help with pain control. Hormonal agents which include levonogestrel intrauterine device, oral contraceptive pills, aromatase inhibitors and gonadotrophin releasing hormone analogues can also be used to help suppress disease symptoms.

Surgical management options include focal resection of lesion (adenomyomectomy) and hysterectomy. Hysterectomy is usually only offered to women who have no desire for future fertilit

Adenomyosis is a difficult diagnosis to manage as multiple clinical factors must be considered, including fertility, confidence in diagnosis, side effects of medical management, and risk of surgery.

Conclusion

Adenomyosis is a problematic diagnosis due to its variable presentation and shared features with other common gynecologic conditions. More research is needed to improve diagnosis and treatment of this condition.

Key Points for Practice:

• Maintain a high index of suspicion in women with heavy, painful menses not explained by fibroids.
• Ultrasound is the most practical diagnostic tool in SSA.
• Initial management should focus on symptom control with NSAIDs, hormonal therapy where available, and iron supplementation.
• Hysterectomy remains the most definitive treatment for women who have completed childbearing, especially where other surgical or fertility-preserving options are limited.
• Early recognition, counselling, and appropriate referral are crucial to improving quality of life and reducing complications from anaemia.