What are the typical symptoms of diffuse adenomyosis in reproductive‑age women?

Symptoms of Diffuse Adenomyosis

Diffuse adenomyosis primarily causes abnormal uterine bleeding (menorrhagia/metrorrhagia) and dysmenorrhea in reproductive-age women, though up to one-third of affected women remain completely asymptomatic. 1

Primary Clinical Manifestations

Bleeding Abnormalities

• Heavy menstrual bleeding (menorrhagia) is the most common presenting symptom, occurring in the majority of symptomatic women with diffuse adenomyosis 1
• Intermenstrual bleeding (metrorrhagia) frequently accompanies heavy menstrual flow 2
• The severity of bleeding correlates with the number of ultrasound features present—women with multiple sonographic findings of adenomyosis demonstrate significantly higher pictorial blood loss analysis chart (PBAC) scores 3
• Chronic heavy bleeding often leads to iron-deficiency anemia requiring evaluation with complete blood count 4

Pain Symptoms

• Dysmenorrhea affects approximately 79% of symptomatic women with sonographic evidence of diffuse adenomyosis 3
• The intensity of dysmenorrhea correlates directly with the number of ultrasound features present (P = 0.005), measured by visual analog scale scores 3
• Chronic pelvic pain occurs independent of menstruation in many affected women 5, 6
• Dyspareunia (painful intercourse) is reported as an associated symptom 5, 2

Critical Diagnostic Context

Asymptomatic Presentation

• Approximately one-third of women with adenomyosis are completely asymptomatic, making this a frequent incidental finding on imaging performed for other indications 5, 2
• The majority of women in retrospective histopathological series were asymptomatic despite confirmed adenomyosis at hysterectomy 2

Physical Examination Findings

• Diffusely enlarged, globular uterus is the classic finding on bimanual pelvic examination 5, 2
• The uterus may demonstrate a boggy consistency on palpation 5
• Uterine tenderness may be present, particularly during menstruation 5

Associated Clinical Features

Reproductive Impact

• Infertility is increasingly recognized as an associated manifestation, with adenomyosis demonstrating negative impact on female fertility 5, 2
• The condition predominantly affects women in their late reproductive years, with 94.5% of diagnosed cases occurring in women over age 40 2

Coexisting Pathology

• Endometriosis coexists in a substantial proportion of women with adenomyosis, complicating the clinical picture 5
• Uterine fibroids (leiomyomas) are present concomitantly in 65.4% of cases, potentially contributing to or masking adenomyosis symptoms 2
• The coexistence of adenomyosis and fibroids significantly contributes to menorrhagia and anemia 4

Age-Specific Considerations

Young Nulligravid Women

• Sonographic features of diffuse adenomyosis can develop earlier in reproductive life than previously recognized, appearing in 34% of symptomatic nulligravid women aged 18-30 years 3
• In this younger population, 83% with sonographic features were symptomatic, with 79.2% reporting dysmenorrhea and 18.9% experiencing heavy bleeding 3
• These findings warrant further gynecological investigation even in young women without prior pregnancies 3

Perimenopausal Women

• The condition classically affects perimenopausal women in their 40s, representing the peak demographic for clinical presentation 5, 2
• Multiparous women comprise 90.6% of diagnosed cases 2

Important Clinical Pitfalls

• Do not dismiss symptoms in young nulligravid women—adenomyosis can present much earlier than traditionally taught, and sonographic features in women aged 18-30 should prompt thorough evaluation 3
• Recognize that absence of symptoms does not exclude adenomyosis—one-third of women are asymptomatic, and the diagnosis may only be made incidentally or at hysterectomy 5, 2
• Consider adenomyosis when fibroids are present—the 65% coexistence rate means adenomyosis may be the primary cause of bleeding symptoms even when fibroids are identified 2
• Evaluate for endometrial cancer in appropriate risk groups—5.5% of women with adenomyosis in one series had concurrent low-grade endometrioid adenocarcinoma, emphasizing the need for endometrial sampling in women over 45 or with risk factors 2