Adenomyosis
Clinical Snapshot
Adenomyosis is a benign, estrogen-dependent condition defined by the presence of endometrial glands and stroma within the myometrium, surrounded by hypertrophic and hyperplastic smooth muscle.[1] It is a genuinely distinct diagnosis from endometriosis — where similar endometrium-like tissue implants outside the uterus altogether — even though the two conditions share much of the same hormonal biology, share several of the same treatments, and are frequently found together in the same patient (see Assessment & Diagnosis).[2] Roughly a third of patients are asymptomatic, with the disease found incidentally on imaging performed for another reason.[2] A major point of diagnostic uncertainty runs through this entire chapter: adenomyosis was traditionally a diagnosis of exclusion confirmed only by histologic examination of a hysterectomy specimen, and more than 80% of women with the disease historically ended up undergoing hysterectomy.[2] Current Canadian guidance supports a non-invasive diagnostic approach using transvaginal ultrasound and MRI, and empiric medical therapy started on that basis, without requiring surgical or histologic confirmation first — but pharmacists should understand that neither imaging modality is perfectly sensitive or specific, so a degree of diagnostic uncertainty is inherent to this disease in a way it is not for many other conditions in this library.[1] This chapter deliberately does not re-teach the full hormonal-therapy ladders already owned by the Dysmenorrhea, Heavy Menstrual Bleeding, and Endometriosis chapters — see those chapters for shared content, cross-referenced throughout below.
Recognize the Condition
The 3 cardinal symptoms are heavy menstrual bleeding (reported in 40-60% of symptomatic patients), dysmenorrhea (15-30%), and chronic pelvic pain, with deep dyspareunia also reported; any combination — or none of these, given how often the disease is asymptomatic — can occur.[2] Symptom severity does not reliably track with the extent of myometrial involvement seen on imaging.
Examination
The classic finding is a diffusely, symmetrically enlarged, soft ("boggy"), and tender uterus, with tenderness often most pronounced just before or during menses — this symmetric, globular enlargement is a useful bedside clue that distinguishes adenomyosis from the irregular, asymmetric enlargement typical of uterine fibroids (see the comparison table in Assessment & Diagnosis). A normal pelvic examination does not exclude the diagnosis, particularly for focal disease.
2 morphologic patterns
Diffuse adenomyosis
The more common pattern — ectopic endometrial tissue and the accompanying smooth-muscle reaction are spread broadly through the myometrium, typically producing symmetric uterine enlargement.
Focal adenomyosis (adenomyoma)
A localized, nodular collection of ectopic endometrial tissue within the myometrium. Because it forms a discrete mass, a focal adenomyoma can mimic a uterine fibroid on both bimanual examination and imaging — MRI is the more reliable modality for telling the two apart when the distinction changes management (see Assessment & Diagnosis).
Risk Factors
- Any prior uterine surgery or instrumentation that disrupts the endometrial-myometrial junction — Cesarean delivery, dilation and curettage, myomectomy, or other uterine instrumentation.
- Multiparity.
- Advancing reproductive age — adenomyosis is most often diagnosed in the 4th and 5th decades of life, though it is increasingly recognized in younger and infertile patients as imaging quality and clinician familiarity with its ultrasound features improve.
- Coexisting uterine leiomyoma (fibroids) — roughly half of patients with adenomyosis also have fibroids, and each condition independently raises the likelihood the other is also present.[2]
- Coexisting endometriosis — the reverse association also holds; see Assessment & Diagnosis for how often the two conditions are found together.
- Early age at menarche has been proposed as a risk factor, though the supporting evidence is weaker and less consistent than for endometriosis.
Red Flags & Refer
Adenomyosis itself is rarely an emergency, but escalate or refer urgently for any of the following:
- Signs of hemodynamic instability from acute heavy bleeding, or symptomatic anemia (significant fatigue, exertional dyspnea, chest pain, marked pallor) — manage per the Heavy Menstrual Bleeding chapter's acute-bleeding pathway rather than this chapter's routine approach.
- Postmenopausal bleeding must never be presumptively attributed to previously known adenomyosis — adenomyosis is estrogen-dependent and characteristically regresses after menopause (see Special Populations), so new bleeding after menopause needs its own prompt endometrial-cancer workup, not reassurance based on an old diagnosis.
- A rapidly enlarging uterine or myometrial mass, or an imaging feature raising concern for malignancy (including leiomyosarcoma, which can be difficult to distinguish from a benign focal adenomyoma or fibroid on ultrasound alone) — refer for gynecologic oncology assessment rather than managing as routine adenomyosis.
- Acute, severe pelvic pain, especially with fever, peritoneal signs, or hemodynamic instability — evaluate for another acute gynecologic or surgical process rather than assuming an adenomyosis flare.
- Any positive pregnancy test accompanying pelvic pain — exclude ectopic pregnancy before attributing pain to adenomyosis.
- Pain or bleeding that remains refractory despite an adequate trial of first- and second-line hormonal therapy — refer for gynecologic reassessment and consideration of surgical evaluation rather than repeating the same medical approach indefinitely.
Assessment & Diagnosis
History and examination
Characterize the bleeding pattern, dysmenorrhea, and any chronic pelvic pain or dyspareunia; ask specifically about prior Cesarean delivery, dilation and curettage, or other uterine instrumentation, and about fertility goals, which materially change the management approach (see Choose Initial Treatment and Special Populations). On bimanual examination, a symmetrically enlarged, soft, tender ("boggy") uterus supports the diagnosis, though a normal examination does not exclude it.
Imaging — the primary diagnostic tools, and their real limitations
Transvaginal ultrasound (TVUS) is the first-line investigation given its accessibility and lower cost. Consensus (MUSA-style) sonographic features fall into 2 groups: direct signs — myometrial cysts, hyperechoic islands, echogenic subendometrial buds/lines, and translesional vascularity on Doppler — and indirect signs — asymmetric myometrial thickening, globular uterine enlargement, fan-shaped shadowing, and an irregular or interrupted junctional zone. A junctional-zone maximum thickness of 8 mm or more on TVUS, fan-shaped striations, and the so-called "question mark" sign are among the more specific individual findings. Reported diagnostic accuracy varies widely by study and by which specific features are used, averaging around 78-85% sensitivity and 64-71% specificity in recent pooled data — meaningfully imperfect, and highly operator-dependent.[3]
MRI trades sensitivity for specificity relative to TVUS (pooled figures of roughly 65-77% sensitivity but 87-89% specificity) and is the more useful confirmatory or problem-solving test — particularly when TVUS is equivocal, when a focal lesion needs to be distinguished from a fibroid before planning a fertility-sparing procedure, or when coexisting deep infiltrating endometriosis is also suspected (see the Endometriosis chapter). Key MRI features include a widened junctional zone (generally 12 mm or more), hyperintense myometrial foci and linear striations on T2-weighted sequences (representing ectopic endometrial glands and hemorrhage), and, for focal disease, an ill-defined T2-hypointense mass without the well-circumscribed pseudocapsule typical of a fibroid.[3]
No blood test or tumour marker reliably diagnoses adenomyosis — none is part of routine workup for this indication.
Adenomyosis, fibroids, and endometriosis: distinguishing and overlapping features
| Feature | Adenomyosis | Leiomyoma (fibroid) | Endometriosis |
|---|---|---|---|
| Location of abnormal tissue | Endometrial glands/stroma within the myometrium | Benign monoclonal smooth-muscle tumour, intramural/submucosal/subserosal | Endometrium-like tissue outside the uterus entirely |
| Uterine contour on exam | Diffusely, symmetrically enlarged, soft ("boggy"), tender | Irregularly enlarged, firm, often nontender; contour reflects fibroid location | Usually normal uterine size; may find a fixed retroverted uterus or adnexal nodularity |
| First-line imaging clue | Interrupted/thickened junctional zone, myometrial cysts, fan-shaped shadowing | Well-circumscribed mass with a distinct pseudocapsule | Endometrioma on the ovary; peritoneal disease is not visible on imaging at all |
| Typical symptom emphasis | Heavy menstrual bleeding and dysmenorrhea together | Bulk/pressure symptoms and heavy bleeding more than pain, unless degenerating | Cyclic, increasingly acyclic pelvic pain, deep dyspareunia, dyschezia |
| How often it coexists with adenomyosis | — | Roughly 50% of adenomyosis patients also have fibroids[2] | Reported in roughly 15-30% of adenomyosis patients across different diagnostic criteria and study populations[4] |
Adenomyosis is the "A" in the FIGO PALM-COEIN classification of structural causes of abnormal uterine bleeding used throughout this platform (see the Heavy Menstrual Bleeding chapter for the full framework).[5] Identifying adenomyosis on imaging does not exclude a second, concurrent PALM-COEIN cause — the same structural workup described in that chapter (pelvic ultrasound, and endometrial biopsy when age or risk factors warrant it) still applies whenever adenomyosis is found.
Treatment Targets
- Reduce menstrual blood loss and relieve dysmenorrhea/chronic pelvic pain to a degree that no longer interferes with the patient's quality of life.
- Identify and directly correct any resulting iron-deficiency anemia — see the Heavy Menstrual Bleeding chapter for anemia workup and treatment, which applies identically here.
- Avoid unnecessary hysterectomy where a fertility-sparing or uterus-sparing medical or procedural option can achieve adequate symptom control, while still identifying the patients who genuinely need definitive surgery.
- Preserve fertility potential and, where pregnancy is being actively pursued, address adenomyosis's own independent negative effect on IVF/ICSI success (see Special Populations) rather than treating it as identical to a fertility-neutral diagnosis.
- Minimize treatment-related adverse effects, particularly the bone mineral density loss associated with prolonged hypoestrogenic GnRH-agonist therapy.
Choose Initial Treatment
Empiric treatment
Start empiric medical therapy based on a supportive history, examination, and imaging pattern — histologic confirmation is not required first.[1]
First-line pharmacotherapy
1st line, contraception desired or acceptable the levonorgestrel-releasing intrauterine system — the same device used for heavy menstrual bleeding — has the strongest overall evidence for adenomyosis-associated bleeding and pain and doubles as long-acting contraception; offer it first when there is no contraindication and the uterine cavity is suitable (full device details and approved durations are in the Heavy Menstrual Bleeding chapter's Drug Tables).
1st line, oral alternative continuous combined hormonal contraception, or an oral progestin — dienogest 2 mg PO daily has the strongest dedicated randomized, placebo-controlled trial evidence specifically in adenomyosis of any oral hormonal option, though it is Health Canada-approved only for endometriosis-associated pain, not for adenomyosis specifically, so its use here is off-label (see Drug Tables).[6]
1st line, non-hormonal tranexamic acid and/or an NSAID on heavy-flow days, particularly when the patient does not want hormonal therapy or contraception, or wants an add-on for incomplete relief — dosing is identical to the Heavy Menstrual Bleeding chapter.
2nd line — once at least 1 first-line hormonal option has had an adequate trial (generally 3-6 months) without adequate relief, or is contraindicated/not tolerated: a time-limited GnRH agonist with mandatory add-back hormone therapy, particularly useful as a bridge to reduce uterine/lesion volume before a planned uterine-sparing procedure — full dosing and the mandatory add-back regimen are in the Endometriosis chapter's Drug Tables and apply unchanged here.
Special situation — fertility is desired avoid all ovarian-suppressing hormonal therapy (it prevents pregnancy); manage pain with NSAIDs and refer for a fertility-focused evaluation. Adenomyosis carries its own independent negative association with IVF/ICSI success distinct from endometriosis — see Special Populations.
Special situation — refractory disease, or childbearing complete and patient prefers definitive treatment refer for gynecologic surgical evaluation. Uterine-sparing procedures (adenomyomectomy for focal disease, uterine artery embolization, or emerging focused-ultrasound ablation) have far more limited and heterogeneous outcome data than the analogous fertility-sparing surgery for endometriosis or fibroids — set expectations accordingly. Hysterectomy remains the only truly definitive treatment and is appropriate for a patient who has completed childbearing and failed medical therapy.
Non-Pharmacologic Treatment
- Have the patient track bleeding and pain using the same pad/tampon-diary approach described in the Heavy Menstrual Bleeding chapter — it both quantifies baseline severity and gives an objective way to judge whether treatment is working.
- Iron-rich dietary counselling for a patient with or at risk of iron-deficiency anemia, alongside — not instead of — oral iron supplementation when indicated.
- Before LNG-IUS insertion, counsel that irregular spotting is expected for the first 3-6 months and does not mean the device has failed; advise waiting at least 6 cycles before judging its effect on bleeding and pain.
Procedural and surgical options
Endometrial ablation
An option when heavy bleeding is the dominant symptom, but its effectiveness is reduced when adenomyosis extends deep into the myometrium — the ablation only treats the endometrial surface, not the disease within the muscle wall itself — so counsel that a patient with significant adenomyosis has a meaningfully higher chance of incomplete or non-durable symptom relief from ablation than a patient with a purely endometrial cause of heavy bleeding.
Adenomyomectomy
Surgical excision of a focal adenomyoma, intended to preserve the uterus. Technically demanding and feasible mainly for focal (not diffuse) disease; outcome data, including for future fertility and pregnancy, remain far more limited than for analogous endometriosis excision surgery, and future pregnancy after adenomyomectomy carries a recognized risk of uterine rupture that needs to be discussed and monitored for.
Uterine artery embolization (UAE)
A minimally invasive, interventional-radiology procedure that reduces bleeding and pain in many patients by inducing focal ischemia in the affected myometrium. Its effect on future fertility is less well established than for fibroid-focused UAE, and it is generally reserved for patients who have completed or are not pursuing childbearing.
Hysterectomy
The only truly definitive treatment, and historically the most common outcome for this disease. Appropriate for a patient who has completed childbearing, has failed or cannot tolerate medical therapy, and desires definitive treatment; the surgical specimen also finally provides the traditional histologic confirmation of the diagnosis in these patients.
Special Populations
Pregnancy
No ovarian-suppressing hormonal therapy (CHC, dienogest or another progestin used for suppression, LNG-IUS insertion, or a GnRH agonist) is started or continued once a patient is pregnant. Manage breakthrough pain with acetaminophen first; avoid NSAIDs from around 20 weeks gestation onward given the risk of fetal renal impairment and premature closure of the ductus arteriosus with later use — the same caution that applies in the Endometriosis chapter. Some observational studies have reported an association between adenomyosis and adverse pregnancy outcomes, including preterm birth, preeclampsia, and postpartum hemorrhage, though the evidence is heterogeneous and adenomyosis is not itself an indication for any specific antenatal intervention beyond standard risk-based obstetric care.
Breastfeeding
Progestin-only options (the LNG-IUS, oral dienogest, or another oral progestin) are generally preferred over an estrogen-containing option if suppressive therapy is needed while breastfeeding, consistent with the Dysmenorrhea and Endometriosis chapters.
Adolescents
Adenomyosis is diagnosed far less often in adolescents than in patients in their 40s, but consider it in an adolescent with heavy bleeding and/or dysmenorrhea that does not respond to an adequate NSAID and hormonal-contraceptive trial, alongside the broader differential covered in the Heavy Menstrual Bleeding chapter (a bleeding disorder, in particular, needs to be excluded first in this age group). First-line hormonal options remain the same as in adults; use a GnRH agonist more cautiously given ongoing bone mass accrual through adolescence, reserved for severe, refractory disease with mandatory add-back therapy.
Perimenopausal patients
Because adenomyosis is estrogen-dependent, symptoms characteristically improve and the disease itself regresses after natural menopause. For a perimenopausal patient with tolerable symptoms, this makes a time-limited medical "bridge" (hormonal or non-hormonal therapy, reassessed periodically as menopause approaches) a reasonable alternative to proceeding straight to hysterectomy, and this expectation is worth discussing explicitly when the patient is weighing definitive surgery against continued medical management. Any bleeding occurring after actual menopause is a red flag requiring its own workup, never attributed to a prior adenomyosis diagnosis (see Red Flags & Refer).
Patients desiring pregnancy (fertility considerations)
Adenomyosis carries its own independent negative association with IVF/ICSI outcomes, distinct from — and in addition to — any effect from coexisting endometriosis; meta-analytic data have reported a meaningfully decreased probability of clinical pregnancy with adenomyosis present.[2] Ovarian-suppressing hormonal therapy is not used to manage adenomyosis-related infertility, since it prevents pregnancy; for a patient with pain who is not yet ready to conceive, NSAIDs alone are the appropriate pharmacologic option while a fertility-focused plan is developed. Refer to a fertility specialist for assessment — a time-limited course of GnRH-agonist down-regulation before a planned IVF/ICSI cycle is one strategy that has been studied specifically in adenomyosis with the aim of improving implantation outcomes, and should be considered as part of a specialist-directed fertility plan rather than routine adenomyosis management.[1]
Monitoring & Follow-Up
Reassess bleeding and pain severity after an adequate trial of any new therapy — generally 3-6 months, allowing for the LNG-IUS's expected early irregular-spotting phase — before judging it a failure and switching. Recheck CBC (and ferritin if previously low) to confirm anemia is resolving on the chosen regimen plus iron repletion, per the Heavy Menstrual Bleeding chapter. For a patient on a GnRH agonist beyond 6 months, follow the same bone-health monitoring and add-back-therapy reinforcement described in the Endometriosis chapter. Do not repeat imaging routinely in a patient whose symptoms are adequately controlled — reserve repeat ultrasound or MRI for a change in the bleeding or pain pattern, a new red-flag symptom, or specific pre-procedural planning. For a perimenopausal patient on a medical bridge, periodically reassess whether continued treatment is still needed as natural menopausal symptom resolution approaches.
Common Errors to Avoid
- Requiring histologic or hysterectomy-based confirmation before starting empiric medical therapy in a patient with a classic history and a supportive imaging pattern.
- Treating a positive ultrasound or MRI finding as a certain diagnosis, or a negative/equivocal one as fully excluding adenomyosis — both modalities are meaningfully imperfect against the traditional histologic reference standard.
- Attributing new postmenopausal bleeding to a previously known adenomyosis diagnosis instead of investigating it as postmenopausal bleeding.
- Missing a coexisting fibroid, endometriosis, or bleeding disorder because the adenomyosis finding on imaging was assumed to fully explain the presentation.
- Using any ovarian-suppressing hormonal therapy, or an NSAID beyond about 20 weeks gestation, in a pregnant patient.
- Prescribing dienogest or the LNG-IUS for adenomyosis without counselling the patient that this use is off-label in Canada (dienogest is labelled for endometriosis-associated pain; the LNG-IUS is labelled for idiopathic menorrhagia).
- Continuing a GnRH agonist beyond 6 months without adding estrogen-progestogen add-back therapy.
- Recommending endometrial ablation without counselling that deep myometrial involvement lowers the chance of durable symptom relief.
- Prescribing tranexamic acid without checking for a personal/family thrombosis history, or before the cause of irregular bleeding has been established, per the same caution that applies in the Heavy Menstrual Bleeding chapter.
- Applying the same fertility-preservation reasoning used for endometriosis without recognizing that adenomyosis has its own independent, additional negative association with IVF/ICSI success.
Clinical Decision Algorithm
Drug Tables
How to use this table: Doses are adult doses and require patient-specific confirmation (renal/hepatic function, weight, allergy history). Pediatric dosing is weight-based per the current product monograph unless stated. Drug pricing is intentionally omitted. Select any drug name to open its complete Pharmasist Drug Database page.
Non-Hormonal Options
Antifibrinolytic and NSAIDs
Taken only on heavy-flow days, exactly as described in the Heavy Menstrual Bleeding chapter. Listed here only to show typical adult dosing for a patient presenting with adenomyosis-associated bleeding; see that chapter for the complete class detail, contraindications, and renal adjustment.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Tranexamic acid | Adults: 1 g PO 3-4 times daily, starting once heavy bleeding begins, for several days while flow remains heavy | Nausea, vomiting, diarrhea; rare visual disturbance with prolonged use | Additive VTE risk with a combined hormonal contraceptive | Contraindicated with a personal history/risk of thrombosis. See Heavy Menstrual Bleeding chapter for the renal-impairment dose-adjustment table. |
| Mefenamic acid | Adults: 500 mg PO TID, started with or the day before bleeding, continued 3-5 days | Dyspepsia, nausea, headache | Increased GI bleeding risk with SSRIs or anticoagulants | Treats both bleeding and dysmenorrhea at once — a practical advantage in adenomyosis, where both symptoms often coexist. |
Hormonal Therapy
Levonorgestrel-releasing intrauterine system
The single most effective medical option for adenomyosis-associated bleeding and pain, and simultaneously long-acting contraception. Full device detail (insertion, approved durations, and the distinction between its contraception-only and menorrhagia-treatment approved durations) is in the Heavy Menstrual Bleeding chapter.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Levonorgestrel-releasing intrauterine system | Adults: One 52 mg system inserted intrauterine by a trained clinician | Irregular spotting (especially first 3-6 months), amenorrhea over time, insertion-related pain, rare perforation | None significant — minimal systemic absorption | On-label when heavy bleeding is the presenting problem (idiopathic-menorrhagia indication) regardless of adenomyosis being the identified cause; using it for adenomyosis pain alone without significant heavy bleeding is a more clearly off-label extrapolation. |
Oral progestin
Dienogest has the strongest dedicated randomized, placebo-controlled trial evidence specifically in adenomyosis of any oral hormonal agent — a 16-week trial found significant reductions in adenomyosis-associated pain versus placebo.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Dienogest | Adults: 2 mg PO once daily, continuous | Breakthrough bleeding/spotting (especially early), headache, breast discomfort, weight gain, mood changes; decreased bone mineral density with prolonged use | CYP3A4 substrate — levels increased by azole antifungals, macrolide antibiotics, and protease inhibitors; decreased by antiepileptics, rifampin, and dexamethasone | Health Canada-approved indication is endometriosis-associated pelvic pain — its use for adenomyosis specifically is off-label in Canada, though supported by dedicated trial evidence.<cite data-reference-id="e0889a3a-009b-4ddf-83d6-80b6ade3f29c"></cite> |
| Norethindrone acetate | Adults: 5 mg PO daily, titrate as needed to a maximum of 15 mg/day | Breakthrough bleeding, weight gain, mood changes | CYP3A4 substrate — see interactions above | An alternative oral progestin option; ovulation resumes promptly after stopping. See the Endometriosis and Dysmenorrhea chapters for full dosing detail. |
Combined hormonal contraceptive (continuous)
An alternative when the LNG-IUS is declined or unsuitable and the patient prefers an estrogen-containing option. Confirm no CHC contraindication first — see the Dysmenorrhea or Endometriosis chapter for the full contraindication list and ACHES counselling.
| Drug | Dosage | Adverse effects | Drug interactions | Comments |
|---|---|---|---|---|
| Ethinyl estradiol / norethindrone acetate (representative monophasic COC) | Adults: 1 tablet PO daily, continuous | Breakthrough bleeding/spotting (especially early on continuous use), nausea, breast tenderness, mood changes; rare but serious VTE, stroke, MI | Efficacy reduced by strong CYP3A4 inducers (rifampin, certain anticonvulsants, St. John's wort) | Continuous (extended-cycle) use — no hormone-free interval — is generally preferred over cyclic use for symptom control. |
2nd-Line and Refractory-Disease Options
A time-limited GnRH agonist with mandatory add-back hormone therapy — the identical regimen and dosing already detailed in the Endometriosis chapter's Drug Tables (leuprolide acetate, goserelin, triptorelin, or nafarelin, each requiring add-back for any course beyond a brief initial trial) — is used for adenomyosis refractory to first-line therapy, or as a pre-procedural bridge to reduce uterine/lesion volume before a planned uterine-sparing procedure.[1] GnRH antagonists (elagolix, or the relugolix/estradiol/norethindrone acetate combination) are Health Canada-approved only for endometriosis-associated pain — using either for adenomyosis specifically is off-label and should be reserved for specialist-directed refractory cases; see the Endometriosis chapter's Drug Tables for their full dosing and contraindications.
References
- Guideline No. 437: Diagnosis and Management of Adenomyosis — Journal of Obstetrics and Gynaecology Canada, Society of Obstetricians and Gynaecologists of Canada (Dason ES, Maxim M, Sanders A, Papillon-Smith J, Ng D, Chan C, Sobel M). J Obstet Gynaecol Can 2023;45(6):417-429.e1
- Adenomyosis: Diagnosis and Management — American Family Physician (Schrager S, Yogendran L, Marquez CM, Sadowski EA). Am Fam Physician 2022;105(1):33-38
- Advances in non-invasive diagnosis of uterine adenomyosis: a narrative review — Gynecology and Pelvic Medicine (Gallo R, Kamberaj L, Baroni A, De Cicco Nardone A, Scambia G, Masciullo V). Gynecol Pelvic Med 2025;8:13
- Global prevalence of adenomyosis and endometriosis: a systematic review and meta-analysis — Reproductive Biology and Endocrinology (Wang MH, Chen JH, Qi XY, Li ZX, Huang Y). Reprod Biol Endocrinol 2025;23(1):148
- The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions — International Journal of Gynecology & Obstetrics, FIGO Menstrual Disorders Committee (Munro MG, Critchley HOD, Fraser IS). Int J Gynaecol Obstet 2018;143(3):393-408
- Evaluation of the efficacy and safety of dienogest in the treatment of painful symptoms in patients with adenomyosis: a randomized, double-blind, multicenter, placebo-controlled study — Fertility and Sterility (Osuga Y, Fujimoto-Okabe H, Hagino A). Fertil Steril 2017;108(4):673-678
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.