Guideline sources The following summarized guidelines for the evaluation and management of adenomyosis are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023), the European Society of Human Reproduction and Embryology (ESHRE 2023), and the Royal College of Obstetricians and Gynaecologists (RCOG 2012). 1 2 3 Guidelines 1. Screening and diagnosis Clinical presentation: recognize that adenomyosis is associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes. B Indications for testing: consider obtaining a 2D ultrasound to rule out adenomyosis in all patients with recurrent pregnancy loss. C 2. Diagnostic investigations https://web.pathway.md/diseases/recfeoh8FO42JbZbf 1/3 6/23/23, 2:09 AM Adenomyosis Pathway Diagnostic imaging: As per SOGC 2023 guidelines, obtain a transvaginal ultrasound as first-line imaging of suspected adenomyosis in patients with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes. A Show 2 more As per RCOG 2012 guidelines, obtain pelvic imaging (transvaginal ultrasound or MRI) for the diagnosis of adenomyosis. B 3. Medical management Hormonal therapy: offer oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest as first-line therapy for pain and heavy menstrual bleeding in patients with adenomyosis. B Show 2 more 4. Therapeutic procedures Uterine artery embolization: consider offering uterine artery embolization for heavy bleeding and pain associated with adenomyosis in patients completed child-bearing and wishing to preserve their uterus. B Thermal ablation: do not offer minimally invasive thermal ablation procedures (such as high- intensity focused ultrasound, radiofrequency ablation, and percutaneous microwave ablation) for the treatment of symptomatic adenomyosis outside of a research context. D 5. Perioperative care Correction of anemia: correct anemia (Hgb < 120 g/L) before adenomyomectomy given the substantial risk of intraoperative hemorrhage. B 6. Surgical interventions Adenomyomectomy: perform adenomyomectomy as a treatment option in patients with symptomatic adenomyosis. B Show 2 more Total hysterectomy: consider offering total hysterectomy for symptomatic adenomyosis in patients completed child-bearing, after appropriate counseling regarding risks, benefits, and alternative treatments. B 7. Patient education https://web.pathway.md/diseases/recfeoh8FO42JbZbf 2/3 6/23/23, 2:09 AM Adenomyosis Pathway Fertility counseling: counsel patients undergoing fertility treatments that the impact of adenomyosis on pregnancy outcomes is uncertain. B Preoperative counseling: Counsel patients undergoing adenomyomectomy about the uncertain impact of this procedure on fertility and pregnancy, including the increased risk of uterine rupture during pregnancy and the need for pre-labor Cesarean delivery. B Counsel patients with dysmenorrhea undergoing surgical management of adenomyosis to have concurrent excision of any coexisting endometriosis during surgery for more complete relief of their symptoms. B References 1. E Shirin Dason, Madalina Maxim, Ari Sanders et al. Guideline No. 437 Diagnosis and Management of Adenomyosis. J Obstet Gynaecol Can. 2023 Jun;45 6 417 429.e1. Open 2. Royal College of Obstetricians and Gynaecologists. The Initial Management of Chronic Pelvic Pain. RCOG. 2012 May. Open 3. ESHRE Guideline Group on RPL, Ruth Bender Atik, Ole Bjarne Christiansen et al. ESHRE guideline: recurrent pregnancy loss: an update in 2022. Hum Reprod Open. 2023 Mar 2;2023 1):hoad002. Open 4. Xuan Che, Jianzhang Wang, Wenting Sun et al. Effect of Mifepristone vs Placebo for Treatment of Adenomyosis With Pain Symptoms: A Randomized Clinical Trial. JAMA Netw Open. 2023 Jun 1;6 6):e2317860. Open https://web.pathway.md/diseases/recfeoh8FO42JbZbf 3/3