Adenomyosis

By RRM Academy Reviewed by Dr. Naomi Whittaker, MD, Board-Certified OBGYN, MIGS, NFPMC, FCI Updated June 17, 2026

Adenomyosis is a condition in which endometrial-like glands and stroma are present within the myometrium (uterine muscle wall), causing the uterus to enlarge and the junctional zone to thicken. The condition causes heavy periods, dysmenorrhea, dyspareunia, intermenstrual bleeding, and impaired fertility. It can also be asymptomatic and discovered incidentally.¹²

The most important clinical distinction the literature has too often collapsed is this: adenomyosis is not one disease. It comprises two subtypes, diffuse and focal, that differ meaningfully in presentation, fertility impact, and treatment path.¹²³

Diffuse adenomyosis is the more familiar form: endometrial-like tissue grows into the myometrium throughout the uterine wall, producing a globally enlarged, boggy uterus. It is seen more commonly in women who have had multiple pregnancies. Definitive diagnosis is histologic, classically by examination of the junctional zone after hysterectomy; contemporary practice diagnoses on clinical suspicion plus imaging, which can strongly suggest but not formally confirm the condition.²³ Importantly, diffuse adenomyosis does not necessarily impair fertility. It is frequently found in women who have already had children, and many conceive without difficulty. High-quality, subtype-specific fertility data remain limited, and a meta-analysis of the literature found that subtype alone (focal versus diffuse) does not significantly change reproductive outcome.⁴ Diffuse disease is more strongly associated with heavy bleeding and pain than with infertility.

Focal adenomyosis presents differently. It includes adenomyomas, which are mass-like lesions that can mimic fibroids on imaging, and cesarean-scar defects (isthmocele) where endometrial-like tissue grows into the uterine scar. Ultrasound is somewhat more useful for focal lesions than for diffuse disease, but it still cannot formally establish the diagnosis.¹² Treatment diverges sharply from the diffuse path: focal lesions are amenable to conservative surgical resection, preserving uterine function. For women who want to conceive, excision of focal disease is the uterine-preserving, restorative surgical path.¹³ When diffuse disease is severe and other management has failed, hysterectomy may be the only definitive resolution.²

Fertility impact is significant for women who do have adenomyosis-related reproductive dysfunction. A meta-analysis found women with adenomyosis had a 28% lower probability of clinical pregnancy and more than twice the odds of miscarriage (OR 2.17) compared to women without the condition.¹ These figures come from assisted-reproduction populations where disease burden and comorbidities are often significant; they should be read as markers of association, not deterministic predictions.

A clinical concern worth naming directly: increasingly sensitive ultrasound has broadened detection of adenomyosis substantially. Prevalence estimates in the literature range from 5% to 70%, a span that reflects how much diagnostic criteria and imaging sensitivity vary.⁴ When imaging over-attributes infertility to the uterus, women may be directed toward interventions that do not treat the underlying disease. IVF is not a treatment for adenomyosis. It does not remove or regress the disease. What IVF protocols attempt to do is optimize conception around a diseased uterus, a fundamentally different goal from treating the condition itself. The disease-directed path for focal adenomyosis is surgical resection. For diffuse disease where fertility is desired and the uterus is to be preserved, management focuses on controlling heavy bleeding and pain as the primary goals.

In restorative reproductive medicine, adenomyosis is evaluated as a distinct condition requiring subtype-specific assessment, not a default explanation for infertility. NaProTechnology-trained clinicians evaluate adenomyosis in the context of the full cycle picture, including luteal phase hormonal patterns and cycle charting data, recognizing that heavy bleeding and progesterone-deficiency patterns often coexist without one being the simple cause of the other. Suppressive medications mask symptoms without addressing disease progression. The restorative principle is to identify and treat the actual lesion, not the symptom it produces.

This content is for educational purposes only and does not constitute medical advice. Consult an RRM clinician or healthcare provider for guidance specific to your situation.