Clinical Profile and Management Outcomes of Women with Adenomyosis: A Prospective Review from a Fertility Centre in Nigeria

This was a prospective descriptive study conducted at Alps Hospitals and Diagnostics, Jos, Nigeria, a private fertility centre. The centre provides specialized reproductive health services, including diagnosis and management of gynaecological conditions, including infertility. A total of 1820 women were attended to, and a total of 1056 had various forms of fertility treatment during the study period. We evaluated women with adenomyosis who received care between June 2021 and December 2024. Eligible participants for this study were: women with infertility diagnosed either pre-operatively by transvaginal ultrasonography using standardized sonographic criteria or intraoperatively based on macroscopic uterine features suggestive of adenomyosis, all surgical patients who had histologic confirmation of adenomyosis, patients who underwent medical treatment and women whose data are available for follow-up. Adenomyosis was diagnosed using the Morphologic Uterus Sonographic Assessment (MUSA) criteria, based on the presence of direct (myometrial cysts, hyperechogenic islands, echogenic subendometrial lines/buds) and indirect myometrial features 18 . Women with genital tract malignancy and those who were lost to follow-up were excluded from the study. A total of 44 women who were managed for adenomyosis between June 2021 and December 2024 were consecutively recruited over a 42-week period. Data collected included demographic and clinical characteristics, infertility duration, presenting symptoms, prior uterine surgeries, diagnostic methods, intraoperative findings, adenomyosis type, associated pelvic pathology, treatment modalities, complications, symptom scores, and reproductive outcomes. Management was individualized based on disease characteristics and fertility preferences, including double-flap adenomyomectomy for diffuse adenomyosis, wedge resection for focal disease, hysterectomy for women without fertility desire, and gonadotropin-releasing hormone agonist therapy for selected patients. Postoperative follow-up was conducted fortnightly for one month and monthly for two additional months, with VAS assessment of menorrhagia and dysmenorrhoea at 1, 3, 6, and 12 months. Symptom severity was rated on a 0–10 scale. Women desiring pregnancy were offered in vitro fertilization after one year of follow-up using appropriate IVF protocols. Data were entered and analysed using the Statistical Package for the Social Sciences (SPSS) version 30. Normality of data was determined using the Shapiro-Wilk test. Continuous variables were expressed as mean ± standard deviation, while categorical variables were summarised as frequencies and percentages. Student's t-test was used to compare the VAS scores between double flap adenomyomectomy and wedge resection. A p-value < 0.05 was considered statistically significant. Ethical approval for the study protocol was obtained on 5 th May, 2021, from the research ethical committee of Alps Hospitals and Diagnostics with reference number ALPS/ADM/001/1025. Patient confidentiality was ensured by ensuring that no identifying information was included in the proforma, analysis or reporting.

This study prospectively examines 44 women who were managed for adenomyosis. Table 1 shows the demographic and clinical characteristics of participants. The mean age of patients was 39.5 ± 5.1 years. The modal age range was 40-49 years, and this accounted for 52.3% of participants. Most patients were nulliparous, and the mean duration of infertility was 7.4 years. The most common menstrual symptom was combined dysmenorrhoea and menorrhagia, reported by 63.6% of patients. Isolated dysmenorrhoea and isolated menorrhagia were less frequent, while 6% of women were asymptomatic. A history of previous uterine surgery was present in the majority (79.6%) of patients. The most common uterine surgery was curettage (25%) and myomectomy (25%). Some patients had multiple surgeries in the past; 20.4% of the participants had curettage+myomectomy. Adenomyosis was diagnosed by ultrasonography in the majority (54.5%) of the patients, while the remaining cases were identified intraoperatively. All tissues were confirmed by histology postoperatively. Demographic and Clinical Characteristics of Participants Diffuse adenomyosis was more common (52.3%) than focal disease (47.7%). Uterine fibroids co-existed with adenomyosis in nearly 80% of patients. The duration of surgery was higher in women who had double flap adenomyomectomy than wedge resection 135.9 ± 75.6 minutes versus 94.5 ± 41.2 minutes. Fertility-preserving surgical procedures were the most commonly employed treatment option. These included double-flap adenomyomectomy (54.5%) and wedge resection (29.5%). Hysterectomy was performed in only one patient. The other intraoperative findings are shown in Table 2 . Intraoperative Findings and Interventions Patients treated with GnRH (13.6%) analogues initially experienced improvement in symptoms, but symptom severity increased during subsequent follow-up visits. From Table 2 , three patients (33.3%) out of a total of 9 women achieved positive pregnancy tests following IVF treatment. However, 2(22.2%) pregnancies resulted in miscarriage, and only one patient achieved a live birth. A total of 10 women had complications following treatment; 4 out of the 6 women who had medical treatment had hot flushes, and this constituted 9.1% of study participants. Surgical site infection occurred in 3(6.8%) of the participants. When both surgical techniques were compared ( Figures 1 and 2 ), they resulted in substantial reductions in VAS scores for dysmenorrhoea and menorrhagia over the follow-up periods. However, no statistically significant difference was observed between the two surgical techniques in terms of symptom improvement. Comparison of VAS Scores for Menorrhagia Between Double- Flap Adenomyomectomy and Wedge Resection Comparison of VAS Scores for dysmenorrhoea between Double-Flap Adenomyomectomy and Wedge Resection Outcomes of Management IVF= In Vitro Fertilization

This study highlights the predominance of reproductive-aged women, the burden of infertility, and the evolving role of conservative surgical techniques in women with adenomyosis in a fertility-focused setting. There was a high proportion (52.3%) of women in advanced reproductive age (40–49 years) in this cohort of women; this reinforces the clinical relevance of fertility-preserving interventions in this group, particularly in this setting where childbearing age is increasing. The mean age of 39.5 years observed in this study aligns with the observed epidemiological pattern of adenomyosis, which predominantly affects women in the late reproductive years [ 19 ]. The predominance of nulliparity (77.3%) and prolonged infertility (mean duration 7.4 years) in women with adenomyosis contradicts earlier descriptions of the pathology as a disease of multiparous women [ 20 ], but nulliparity is increasingly being reported, especially in populations undergoing assisted reproductive techniques [ 20 ]. This shift may reflect improved diagnostic modalities and heightened clinical suspicion among infertile women, as well as the coexistence of adenomyosis with other infertility-associated conditions such as endometriosis and fibroids, both of which were observed in this cohort. Only 13.6% of the participants were without menstrual symptoms. The majority of patients experienced combined dysmenorrhoea and menorrhagia. This symptom complex is consistent with the underlying pathophysiology of adenomyosis, where ectopic endometrial glands within the myometrium lead to hyperperistalsis, myometrial hypercontractility, inflammation, and abnormal uterine bleeding [ 13 , 14 ]. A previous uterine surgery was observed in nearly 80% of the participants; this lends support to the hypothesis that disruption of the endometrial–myometrial interface plays a role in the pathogenesis of adenomyosis [ 7 ]. Procedures such as curettage and myomectomy have been implicated in facilitating myometrial invasion of endometrial tissue, although causality remains debated. A striking finding in this study was that 20.4% of the women did not have a previous uterine surgery. Contemporary evidence shows that adenomyosis occurs without a prior uterine surgery, likely reflecting intrinsic dysfunction of the endometrial-myometrial interface and hormonally driven tissue remodelling [ 7 , 22 ]. Ultrasonography was the most common diagnostic modality, reflecting its accessibility and utility in resource-limited environments. However, the substantial proportion of intraoperative diagnosis highlights the ongoing challenges in the preoperative identification of adenomyosis. While magnetic resonance imaging (MRI) remains the gold standard for diagnosis, its limited availability in many settings necessitates reliance on ultrasound, which has shown improved diagnostic accuracy with advancing expertise [ 23 ]. The intraoperative finding of an average uterine size of 17.3 ± 2.5 weeks is consistent with reports by Osada et al [ 24 ]. This large uterine size also points to the chronicity of this condition and late presentation in our environment. The predominance of conservative procedures reflects a deliberate effort to preserve fertility. The double flap adenomyomectomy was the most frequent conservative surgery. Open flap adenomyomectomy is better suited for diffuse adenomyosis as it allows a more radical excision of the adenomyoma tissues [ 24 ]. One woman who was no longer desirous of conception had a hysterectomy. Hysterectomy is a definitive treatment, but this is not an option where future conception is desired. Uterine fibroids coexisted with adenomyosis in 79.5% of cases; it shares overlapping signs and symptoms yet differing pathophysiology and imaging characteristics, which may complicate diagnosis and management [ 25 ]. Endometrioma observed in 9.1% of this cohort is consistent with findings from other studies that revealed that it coexists with adenomyosis in 10-25% of cases [ 26 , 27 ]. The operative duration and blood loss associated with adenomyomectomy were higher compared to wedge resection, consistent with the technical complexity of the procedure. Nonetheless, complication rates were relatively low and comparable to existing literature, suggesting that these procedures can be safely performed in appropriately selected patients [ 2 ]. Importantly, both surgical approaches were associated with sustained improvement in symptom severity over time, as demonstrated by reductions in VAS scores for dysmenorrhoea and menorrhagia. The absence of statistically significant differences between the two techniques suggests that both may be effective options, with choice guided by disease extent, surgeon expertise, and reproductive goals. This finding aligns with previous studies indicating that conservative surgery can provide meaningful symptom relief in adenomyosis [ 28 ]. The reproductive outcomes following conservative surgery and medical treatment remain modest despite significant symptomatic relief. Only 1 pregnancy resulted in a live birth following IVF. This is consistent with existing evidence that adenomyosis adversely affects implantation, pregnancy maintenance, and overall IVF success rates [ 29 ]. The high miscarriage rate observed further underscores the detrimental impact of adenomyosis on reproductive outcomes, possibly mediated through impaired endometrial receptivity and altered uterine contractility. While surgical intervention has been proposed to improve fertility outcomes, the evidence remains mixed, and further prospective studies are needed to clarify its role [ 30 ]. The focus of this study within an infertility population, an area of immense clinical relevance in our setting, is a major strength of this study. The prospective nature of the study reduced the possibility of incomplete or missing data. The inclusion of both clinical and intraoperative findings, assessment of VAS scores for symptoms and fertility outcome allowed objective assessment of symptom improvement and reproduction. This study has some limitations which should be considered when interpreting the findings. This study was a single centre study with a small sample size; this reduces the power of the study and limits its generalisability to a wider population. Also, the duration of follow-up in this study may not have been sufficient to fully evaluate long-term recurrence rates. In conclusion, adenomyosis predominantly affects infertile nulliparous women in the late third decade of life with previous uterine surgeries in this cohort. Combined menorrhagia and dysmenorrhoea were the most frequent presentation and co-exist with other pelvic pathologies. Open flap adenomyomectomy and wedge resection may provide sustained symptom relief, while medical therapy alone provides temporary symptom relief. However, reproductive success remains a challenge in this group of women.

Adenomyosis is a benign uterine disorder that has a major impact on the quality of life of affected women 1 . It is characterized by abnormal invasion of endometrial gland and stroma into the surrounding myometrium[ 2 ]. The prevalence is uncertain; some studies have suggested that it affects 20-40% of women[ 3 , 4 ]. It has been estimated that adenomyosis affects about 31% of women with infertility compared to lower rates in the general population, underscoring its relevance in fertility care[ 5 ]. Initially, it was thought to affect predominantly women over 40 years, but studies in infertile women revealed its presence in younger women[ 6 , 7 ]. Abnormal invagination of the basalis layer of the endometrium into the myometrium is at the core of the pathophysiology of adenomyosis[ 8 ]. Mechanical disruption of the endometrial-myometrial interface through curettage and other uterine surgeries like caesarean section has been linked to endometrial invagination[ 9 ]. Disordered uterine contractility and hyperperistalsis can cause auto-trauma to the junction, leading to invasion of endometrial tissues into the myometrium[ 10 ]. Elevated levels of estradiol and aromatase in the menstrum and endometrium of patients with adenomyosis support the suggestion that elevated levels of estradiol are necessary for the development and maintenance of adenomyosis [ 6 , 10 ]. Focal adenomyosis is a category of adenomyosis in which endometrial tissues are deposited in a localized area of the myometrium, and diffuse adenomyosis, which is the extensive form of the disease, characterized by foci of endometrial mucosa (glands and stroma) scattered throughout the uterine musculature [ 11 ]. Impaired fertility in adenomyosis is thought to result from altered myometrial contractility, which affects sperm and embryo transport, and compromised chronic intrauterine inflammation, which affects endometrial receptivity [ 12 ]. According to reports, adenomyosis is associated with low clinical pregnancy and live birth rates and an elevated odds of miscarriage after assisted reproduction compared to women without the condition [ 12 ]. Menorrhagia is suggested to result from hormonally responsive endometrial glands and stroma within the myometrium that proliferate and shed with each menstrual cycle, increasing the bleeding surface and ineffective uterine contractions during menstruation with resultant ineffective haemostasis [ 13 ]. Uterine hypercontractility due to elevated oxytocin, vasopressin, and inflammatory mediators that stimulate the production of uterotonic and pain-mediating prostaglandins is a suggested mechanism of dysmenorrhea [ 14 ]. Adenomyosis tends to be diagnosed incidentally following histopathologic assessment of uterine tissues from gynaecologic surgeries, this is despite significant development in diagnostic imaging [ 15 , 16 ]. Serum biomarkers with a role in the pathogenesis of adenomyosis, such as microRNAs, have emerged as potential diagnostic tools; however, it requires validation in future research [ 17 ]. The management option for adenomyosis depends on the patients' symptomatic burden and reproductive goals. Medical therapy with hormonal agents and fertility-sparing surgeries such as adenomyomectomy and image-guided thermal ablation have demonstrated promising reproductive outcomes in carefully selected women who desire fertility [ 15 ]. Adenomyosis is both a cause of symptomatic morbidity and also a modifiable factor influencing reproductive outcomes, therefore addressing adenomyosis within the fertility care pathway is critical. The aim of this study is to assess the profile of women with adenomyosis and the management outcomes. A comprehensive understanding of its clinical profile and management outcomes in the context of a fertility setting will better inform counselling, therapeutic decision-making and personalized care strategies that may improve quality of life and reproductive potential.