Adenomyosis — endometrial tissue growing within the muscular wall of the uterus — causes heavy bleeding, severe cramping, a bulky tender uterus and, often, years of being told that periods are simply difficult. Because it was historically diagnosed only on pathology after hysterectomy, it was systematically under-recognised. Standardised ultrasound criteria have quietly ended that era.
How it differs from fibroids and endometriosis
Fibroids are discrete, well-defined lumps. Adenomyosis is diffuse infiltration of the uterine muscle, which is why it produces a uniformly enlarged, boggy, tender uterus rather than a palpable mass. Pain is typically deep, cramping and worsens progressively through the period.
It frequently coexists with endometriosis, and the overlap is one reason women treated for one condition may still have symptoms — the other was never addressed.
A normal routine scan does not exclude adenomyosis. It has to be looked for specifically, by someone who knows the criteria.
Diagnosis in 2026
Standardised sonographic criteria — an asymmetrically thickened myometrium, myometrial cysts, echogenic subendometrial lines and buds, a poorly defined junctional zone — now allow confident diagnosis on high-quality transvaginal ultrasound by an experienced operator. MRI adds detail in complex cases and before surgery.
The practical point for patients: the scan must be done by someone specifically looking for adenomyosis. A routine scan reported as normal does not rule it out.
Treatment that preserves the uterus
The hormonal intrauterine system is first-line for many women and often dramatically reduces bleeding and pain. Other hormonal options, tranexamic acid for bleeding and anti-inflammatories all have a role.
For focal adenomyosis, laparoscopic excision of the affected area can preserve the uterus and fertility in carefully selected patients. Hysterectomy remains definitive and is a good choice for women who have completed their family and want a certain end to symptoms.
Adenomyosis and fertility
Adenomyosis is associated with lower implantation rates and higher miscarriage risk, though many women with it conceive without difficulty. Where fertility is a priority, treatment is planned specifically around it — often medical suppression before conception attempts, or targeted surgery in focal disease.
Signs that should prompt assessment
- Periods that are both very heavy and increasingly painful
- A feeling of pelvic heaviness or a bulky, tender uterus
- Pain that worsens through the period rather than easing
- Persistent symptoms despite fibroid or endometriosis treatment
Common questions
Is hysterectomy the only cure for adenomyosis?
It is the only definitive cure, but many women achieve excellent long-term control with hormonal treatment, and selected patients with focal disease benefit from uterus-preserving surgery.
Can I get pregnant with adenomyosis?
Yes, many women do. Where adenomyosis is extensive, a fertility-focused plan before conception attempts improves the odds and should be discussed early.
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