How can I differentiate between adenomyosis and other causes of dysmenorrhea in my patients?

Differentiating adenomyosis from other causes of dysmenorrhea involves a combination of clinical assessment and targeted imaging investigations. Clinically, adenomyosis often presents with heavy menstrual bleeding and significant dysmenorrhea, sometimes accompanied by a bulky, tender uterus on pelvic examination, which can help distinguish it from other causes such as endometriosis or fibroids ².

Initial assessment should include a detailed menstrual and pain history, focusing on the severity and impact of dysmenorrhea, and a pelvic examination to detect uterine enlargement or tenderness suggestive of adenomyosis ²,¹. Unlike endometriosis, which may present with cyclical pelvic pain, deep dyspareunia, and bowel or urinary symptoms, adenomyosis symptoms are more centered on uterine-related pain and bleeding ¹.

Transvaginal ultrasound is the preferred first-line imaging modality to evaluate suspected adenomyosis, especially in women with heavy menstrual bleeding and dysmenorrhea or a bulky uterus on examination ². Ultrasound features suggestive of adenomyosis include a heterogeneous myometrium, myometrial cysts, and asymmetrical thickening of the uterine walls ²[(Ren et al., 2024)].

While MRI can be used for further assessment, especially in complex cases, transvaginal ultrasound remains the practical and accessible choice in general practice ²[(Struble et al., 2016)]. It is important to note that adenomyosis can coexist with other pathologies such as fibroids or endometriosis, so a comprehensive assessment is essential ¹[(Wéry et al., 2005)].

Serum CA125 is not recommended for diagnosis, and definitive diagnosis may require specialist imaging or histopathology, but initial differentiation relies heavily on clinical features and ultrasound findings ¹,².

In summary, to differentiate adenomyosis from other causes of dysmenorrhea:

• Take a thorough history emphasizing heavy menstrual bleeding and uterine pain.
• Perform pelvic examination to assess for uterine enlargement and tenderness.
• Offer transvaginal ultrasound to identify characteristic myometrial changes.
• Consider referral for specialist imaging or gynaecology assessment if diagnosis remains unclear or symptoms are severe ¹,².