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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Adenomyosis

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Treat acute bleeding and pain by physiology

Adenomyosis commonly causes chronic heavy painful periods, but haemodynamic compromise, pregnancy-related pain, sudden peritonism, fever, postmenopausal bleeding or a rapidly changing mass requires urgent assessment for haemorrhage, ectopic pregnancy, infection, torsion or malignancy.

Action: Check observations and pregnancy status, quantify bleeding, obtain urgent blood count and group testing when appropriate, resuscitate and escalate through acute gynaecology or the relevant cancer pathway rather than attributing every deterioration to established adenomyosis.

Synopsis

Recognise adenomyosis as a myometrial cause of painful heavy bleeding, select appropriate imaging and medical treatment, and counsel accurately about uterine procedures and fertility uncertainty.

  • Adenomyosis is endometrium-like glands and stroma within the uterine muscle, accompanied by surrounding myometrial hypertrophy and inflammation; it is distinct from endometriosis outside the uterus but often coexists with it.
  • Typical features are heavy menstrual bleeding, progressively painful periods, chronic pelvic pain, deep dyspareunia and a diffusely bulky tender uterus, although some people have no symptoms.
  • Take bleeding impact seriously: assess flooding, clots, protection changes, anaemia symptoms, cycle regularity, intermenstrual or postcoital bleeding, pain, pressure and reproductive goals.
  • For heavy bleeding with significant dysmenorrhoea or a bulky tender uterus, NICE recommends transvaginal ultrasound in preference to transabdominal ultrasound or MRI; explain alternatives if internal scanning is declined or unsuitable.
  • Obtain a full blood count for everyone with heavy menstrual bleeding in parallel with treatment; pregnancy, cervical and endometrial testing are driven by the broader presentation rather than by adenomyosis alone.
  • NICE recommends considering a levonorgestrel intrauterine system as the initial HMB treatment for suspected or diagnosed adenomyosis when acceptable, with counselling that bleeding may be irregular and benefit can take at least six cycles.
  • Tranexamic acid, NSAIDs, combined hormonal contraception or cyclical oral progestogens are alternatives when an intrauterine system is declined or unsuitable, selected around contraindications and fertility plans.
  • Uterine artery embolisation can relieve symptoms in a substantial proportion but recurrence and further procedures are possible and fertility effects are uncertain; hysterectomy is definitive uterine treatment when pregnancy is no longer desired.

Key red flags

Syncope, tachycardia, hypotension, chest symptoms or ongoing flooding indicates clinically important blood loss and requires urgent haemorrhage assessment and stabilisation.

A positive pregnancy test with pelvic pain or bleeding redirects care to the early-pregnancy pathway because adenomyosis does not exclude ectopic pregnancy or miscarriage.

Persistent intermenstrual or postcoital bleeding, postmenopausal bleeding or endometrial cancer risk factors require cavity and endometrial assessment rather than imaging-only reassurance.

A discrete, rapidly enlarging or postmenopausal uterine mass, weight loss or constitutional symptoms should not be assumed to be benign diffuse adenomyosis.

Sudden severe pain, guarding, vomiting or fever is atypical for stable adenomyosis and requires evaluation for adnexal, infective, urinary or gastrointestinal emergencies.

Investigation priorities

01
Pregnancy test and full blood countFirst step

Redirect pregnancy-related bleeding and quantify anaemia while symptom treatment and structural assessment proceed.

Management branches

Diagnostic routeConfirm the myometrial pattern

Heavy bleeding accompanies significant dysmenorrhoea, pelvic pain or a bulky tender uterus.

  1. Take a bleeding, pain and cancer-risk history, examine when indicated and obtain pregnancy testing and full blood count in parallel with treatment.
  2. Offer transvaginal ultrasound; if it is declined or unsuitable, discuss transabdominal ultrasound or MRI and their diagnostic limitations.
  3. Use hysteroscopy rather than assuming adenomyosis when persistent intermenstrual bleeding or endometrial risk points to cavity pathology.

Key medicines

Levonorgestrel 52 mg intrauterine systemInsert one 52 mg system into the uterine cavity after excluding pregnancy and assessing infection and uterine anatomy; the cited product is licensed for heavy menstrual bleeding for 5 years.Do not insert with pregnancy, active pelvic infection, unexplained high-risk bleeding or important cavity distortion. Discuss insertion pain, perforation, expulsion, altered bleeding and ovarian cysts; review missing threads, pregnancy symptoms, fever or persistent pain promptly.
Tranexamic acidOnce heavy menstrual bleeding starts, take 1 g orally three times daily for as long as needed up to 4 days; for very heavy loss the total may be increased but must not exceed 4 g in 24 hours.Avoid in active or previous venous or arterial thrombosis, severe renal impairment, consumption coagulopathy and a seizure history; reduce dose for renal impairment, assess irregular bleeding first and use particular caution with combined oral contraception.
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG88: Heavy menstrual bleeding recommendations
  • NICE HTG324: Uterine artery embolisation for adenomyosis
  • NHS: Adenomyosis
  • Electronic Medicines Compendium: Mirena SmPC
  • Electronic Medicines Compendium: Tranexamic acid 500 mg SmPC

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom