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 NICE NG88.
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 NICE NG88,NICE NG73. 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 NICE NG73.
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 NICE NG88. Ultrasound features suggestive of adenomyosis include a heterogeneous myometrium, myometrial cysts, and asymmetrical thickening of the uterine walls NICE NG88[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 NICE NG88[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 NICE NG73[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 NICE NG73,NICE NG88.
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 NICE NG73,NICE NG88.
Key References
- NG73 - Endometriosis: diagnosis and management
- NG88 - Heavy menstrual bleeding: assessment and management
- (Wéry et al., 2005): [Adenomyosis: update on a frequent but difficult diagnosis].
- (Struble et al., 2016): Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition.
- (Ren et al., 2024): Role of ultrasonography in the evaluation of disease severity and treatment efficacy in adenomyosis.