Adenomyosis is defined as the presence of heterotopic endometrial foci within the myometrium accompanied by stromal and smooth muscle hyperplasia. Symptoms are non-specific but are typically characterised by menorrhagia, dysmenorrhoea, and uterine enlargement with one third of women remaining asymptomatic.

Advances in medical imaging have facilitated non-invasive diagnosis. Transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) allow evaluation of myometrial invasion with sensitivities of 72% and 77% and specificities 81% and 89% respectively¹.  Both modalities evaluate disruption to the endomyometrial interface (or junctional zone) however depth of endometrial infiltration required for diagnosis is poorly defined and distorted by body habitus and the presence of fibroids. Consequently, histological diagnosis remains the gold standard and is achieved at hysterectomy or ultrasound guided biopsy as a minimally invasive alternative.

Oral progestogens and combined oral contraception have played an important role in the medical management of menorrhagia and dysmenorrhoea associated with adenomyosis and other causes of abnormal uterine bleeding (AUB). Progestogen induced endometrial atrophy is associated with marked improvement in pain and bleeding however 50% of patients experience recurrence by 6 months². Levonorgestrel-releasing intrauterine devices (Mirena) are inexpensive, well tolerated and achieve symptom control for approximately three years. GnRH antagonism results in hypoestrongaemia and is proven effective in the reduction of chronic pelvic pain associated with adenomyosis. Combination GnRH-a-Mirena therapy performed as a staged procedure has been shown to enhance patient response, result in prolonged uterine involution and reduced rates of IUD expulsion.

Hysterectomy is considered gold standard in the treatment of adenomyosis in women who do not desire uterine preservation and facilitates comprehensive histological assessment. Procedural morbidity in conjunction with increasing maternal age and desire for uterine preservation have resulted in advancements in minimally invasive surgical management.  Classical adenomyomectomy and cytoreductive surgery provide 84.6% and 54.6% reduction in dysmenorrhoea respectively, improved bleeding and post-procedural pregnancy rates of up to 60%³. While these techniques preserve fertility, they confer an increased risk of uterine rupture during subsequent pregnancies. In instances of superficial disease, defined as less than 12mm of myometrial invasion, second generation endometrial ablation offers excellent results with ultrasound guided techniques described as alternatives in cases of deeper disease.