Guideline No. 437: Diagnosis and Management of Adenomyosis

J Obstet Gynaecol Can. 2023 Jun;45(6):417-429.e1. doi: 10.1016/j.jogc.2023.04.008.


Objective: To describe the current evidence-based diagnosis and management of adenomyosis.

Target population: All patients with a uterus of reproductive age.

Options: Diagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).

Outcomes: Outcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).

Benefits, harms, and costs: This guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.

Evidence: Databases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.

Validation methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).

Intended audience: Obstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.

Tweetable abstract: Adenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.

Summary statements: RECOMMENDATIONS.

Keywords: adenomyosis; dysmenorrhea; menorrhagia; sonography; uterine artery embolization.

Publication types

  • Practice Guideline

MeSH terms

  • Adenomyosis* / diagnosis
  • Adenomyosis* / therapy
  • Adult
  • Female
  • Humans
  • Infertility*
  • Menorrhagia*
  • Pelvic Pain
  • Pregnancy
  • Uterus