Adenomyosis Pathophysiology, Diagnostic Advances, and Therapeutic Options

Adenomyosis is a heterogeneous, nonmalignant uterine disorder characterized by ectopic endometrium within the myometrium, leading to abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and subfertility. Once considered a disease of multiparous women older than age 40 years, advances in imaging have expanded recognition to younger reproductive-aged patients. Pathogenesis involves sex steroid imbalance, inflammation, fibrosis, neuroangiogenesis, and stem cell-mediated mechanisms. Clinical presentation ranges from asymptomatic to severe pain and bleeding. Coexisting leiomyomas and endometriosis are common, compounding symptom severity and complicating management. Diagnosis remains challenging given a lack of consensus definitions for histologic diagnosis, although improved imaging techniques have enhanced noninvasive detection. Medical management is extrapolated largely from endometriosis and leiomyoma data, with progestins, levonorgestrel intrauterine systems, gonadotropin-releasing hormone analogs and antagonists, and emerging agents showing variable efficacy. Interventional and surgical options, including uterine artery embolization, radiofrequency ablation, high-intensity focused ultrasound, microwave ablation, and adenomyomectomy, offer symptom relief and uterine preservation, although recurrence and fertility outcomes remain incompletely defined. Adenomyosis imposes a significant burden across physical, psychologic, and socioeconomic domains. Advances in imaging, consensus regarding pathology, and novel therapies are reshaping management, underscoring the need for disease-specific prospective trials and standardized diagnostic criteria to optimize individualized, fertility-preserving care for this common, often misunderstood, condition.