Adenomyosis: still largely under-diagnosed.

Underlying adenomyosis is often the cause of treatment failure for patients undergoing Mirena insertion, endometrial ablation and/or hysteroscopic resection for abnormal uterine bleeding and/or pelvic pain. In this cohort of abnormal uterine bleeding, clinicians rarely considered adenomyosis as a differential diagnosis. In such cases, gynaecologists concentrated primarily on menstrual flow. Symptoms of pelvic pain, dyspareunia, pelvic pressure symptoms and type of dysmenorrhoea were not queried. Frequently, no correlation was sought to account for a uterus noted to be enlarged either clinically or at hysteroscopy. Given the limitation of ultrasound scan (USS) in diagnosing adenomyosis, and gynaecologists' reliance on USS findings, adenomyosis often remains undiagnosed before a hysterectomy. An earlier diagnosis of adenomyosis requires a good history, correlation of clinical examination and ultrasound scan findings and a back-up MRI service. Once adenomyosis is suspected, women can be appropriately counselled so that they are fully aware of the possible failure of conservative management. If conservative management is chosen, they should be followed-up and hysterectomy offered for persistent symptoms.