Diffuse Adenomyosis Coexisting with rASRM Stage IV Endometriosis in a Young Woman: Diagnostic Delay and Imaging Discrepancy

Adenomyosis is increasingly recognized in young women and frequently coexists with endometriosis, suggesting shared pathogenic mechanisms. Delayed recognition of symptoms may contribute to disease progression, while discrepancies between preoperative imaging and intraoperative findings remain a diagnostic challenge. We report a case of diffuse adenomyosis coexisting with revised American Society for Reproductive Medicine (rASRM) stage IV endometriosis, highlighting diagnostic delay and the complementary roles of transvaginal ultrasound (TVUS), magnetic resonance imaging (MRI), and laparoscopy. Case Presentation: A 22-year-old nulligravid woman presented with severe dysmenorrhea since adolescence, accompanied by dyschezia, dysuria during menstruation, and chronic pelvic pain. TVUS demonstrated diffuse posterior adenomyosis according to the Morphological Uterus Sonographic Assessment (MUSA) criteria, bilateral ovarian endometriomas, left hydrosalpinx, a posterior compartment lesion suspicious for deep infiltrating endometriosis (DIE), and a negative sliding sign suggestive of pelvic adhesions. TVUS identified posterior compartment DIE and pelvic adhesions that were subsequently confirmed during laparoscopy, whereas MRI confirmed diffuse adenomyosis and bilateral adnexal disease without identifying posterior compartment involvement. Fertility-preserving laparoscopic adhesiolysis, adenomyomectomy, bilateral ovarian cystectomy, and left salpingectomy were performed. Histopathological examination confirmed adenomyosis and bilateral ovarian endometriomas. Postoperatively, the patient was commenced on dienogest while awaiting future fertility treatment.

This case demonstrates that adenomyosis may occur in young women and coexist with advanced endometriosis. The close anatomical relationship between posterior adenomyosis and posterior DIE provides clinical support for the outside-to-inside pathogenic hypothesis. In this case, TVUS outperformed MRI in detecting posterior compartment disease, illustrating the complementary strengths of multimodal imaging, with laparoscopy remaining the reference standard for definitive assessment.

Persistent dysmenorrhea in young women should not be considered a normal menstrual symptom. Early specialist referral and comprehensive multimodal imaging assessment are essential to reduce diagnostic delay, facilitate fertility-preserving management, and improve recognition of advanced adenomyosis and endometriosis.

adenomyosis, deep infiltrating endometriosis, dysmenorrhea, laparoscopy, magnetic resonance imaging, transvaginal ultrasound

Adenomyosis is a benign gynecological disorder characterized by the presence of endometrial glands and stroma within the myometrium, accompanied by hypertrophy of the surrounding smooth muscle and disruption of the junctional zone. Historically, it has been regarded as a disease affecting multiparous women in later reproductive life and was most commonly diagnosed following hysterectomy. However, advances in non-invasive imaging, particularly transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), have demonstrated that adenomyosis may occur in younger women and can be diagnosed accurately before surgery using standardized imaging criteria. Recent evidence further highlights that adenomyosis in adolescents and young women remains underrecognized despite increasing awareness, contributing to delayed diagnosis and prolonged symptom burden.1–6 Increasing evidence suggests that adenomyosis and endometriosis frequently coexist and may represent overlapping manifestations of a common disease spectrum rather than distinct pathological entities. Shared hormonal, inflammatory, genetic, and molecular mechanisms have been proposed to explain their frequent coexistence, while deep infiltrating endometriosis (DIE) has been implicated in the development of adenomyosis through the proposed outside-to-inside invasion mechanism.1–5 Despite these advances, diagnosis remains challenging in young women because symptoms such as severe dysmenorrhea are often normalized, resulting in delayed referral and progression to advanced disease before definitive diagnosis.7,8 Accurate preoperative assessment is essential for surgical planning and fertility preservation in women with suspected advanced endometriosis. Current international guidelines recommend expert-performed TVUS as the first-line imaging modality, with MRI serving as a complementary investigation for disease mapping and evaluation of lesions beyond the sonographic field of view.6,9 Nevertheless, discrepancies between imaging findings and intraoperative observations continue to occur, particularly in posterior compartment disease and pelvic adhesions, emphasizing the need to understand the complementary strengths and limitations of each modality.10–18 Herein, we report the case of a 22-year-old nulligravid woman with diffuse adenomyosis coexisting with histopathologically confirmed ovarian endometriomas. This case highlights three clinically relevant lessons: adenomyosis should not be excluded solely because of young age; the coexistence of posterior adenomyosis and posterior DIE provides clinical support for the outside-to-inside pathogenic hypothesis; and discordant findings between TVUS and MRI should be interpreted in the context of their complementary diagnostic roles, with laparoscopy remaining the reference standard for definitive assessment of advanced endometriosis. Case Report A 22-year-old nulligravid woman (P0A0), married for six months and desiring future fertility, was referred to our tertiary referral center with a diagnosis of adenomyosis, bilateral ovarian endometriomas, and left hydrosalpinx. She reported severe dysmenorrhea beginning at 13 years of age, approximately one year after menarche. The pain progressively worsened over time, becoming localized predominantly to the left lower abdomen, beginning one to two days before menstruation and persisting until the first day of menses. The severity of pain substantially interfered with her daily activities. Despite longstanding symptoms, medical evaluation was delayed because both the patient and her family considered severe menstrual pain to be a normal menstrual experience. A family history of severe dysmenorrhea was reported in her mother. The chronology of symptom progression, diagnostic evaluation, surgical management, and postoperative follow-up is summarized in Table 1. | Table 1 Timeline of Clinical Presentation, Diagnostic Evaluation, and Management | The patient also experienced dyschezia and dysuria during menstruation, intermittent intermenstrual spotting five days before presentation, and recurrent clear, pruritic, malodorous vaginal discharge. Menstrual cycles were regular every 28–30 days, lasting 6–7 days, with relatively heavy menstrual bleeding during the first three days requiring three to four sanitary pads daily. Menarche occurred at 12 years of age. She denied weight loss, anorexia, or other constitutional symptoms. General physical examination was unremarkable. Pelvic examination demonstrated normal vulvar, vaginal, and cervical findings. Bimanual examination revealed no palpable adnexal mass or obvious uterine enlargement. Transvaginal ultrasound was performed by a gynecologist experienced in gynecologic ultrasound. The examination demonstrated a retroflexed uterus measuring 6.96×3.7 × 4.4 cm. A diffuse hyperechoic lesion was identified in the posterior uterine wall, consistent with diffuse adenomyosis. The sonographic features included heterogeneous myometrial echotexture, asymmetrical posterior myometrial thickening, and an indistinct junctional zone, in accordance with the Morphological Uterus Sonographic Assessment (MUSA) criteria. The right ovary contained multiple cystic lesions with ground-glass appearance measuring 2.2×1.6 cm, 1.6×1.09 cm, and 1.33 cm. The left ovary demonstrated a cystic lesion measuring 3.52×3.58 × 2.89 cm with similar features, consistent with bilateral ovarian endometriomas. A hypoechoic nodule measuring 2.44×1.94 cm was identified in the posterior pelvic compartment, suspected to originate from the bowel, suggesting deep infiltrating endometriosis (DIE). In addition, a tubular hypoechoic structure measuring 12.33×3.7 cm with mobile septations was observed, consistent with hydrosalpinx. The sliding sign was negative, indicating reduced organ mobility and suggesting pelvic adhesions (Figure 1). Pelvic magnetic resonance imaging (MRI) was performed using a 3.0-T scanner before and after intravenous contrast administration with T1-weighted, T2-weighted, T2 short tau inversion recovery (STIR), contrast-enhanced T1-weighted fat-suppressed, diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) sequences acquired in axial, sagittal, and coronal planes. MRI demonstrated posterior junctional zone thickening with multiple intramyometrial foci infiltrating the posterior myometrium, consistent with diffuse adenomyosis. Bilateral ovarian cystic lesions and bilateral thick-walled tubular adnexal structures suggestive of salpingitis were also identified, together with a small pelvic fluid collection. However, MRI did not demonstrate definite posterior compartment deep infiltrating endometriosis or pelvic adhesions. The patient subsequently underwent fertility-preserving laparoscopic surgery. Intraoperatively, the uterus appeared globular with diffuse posterior wall thickening consistent with adenomyosis. Grade II–III pelvic adhesions involved the posterior compartment, with dense adhesions between the posterior uterine wall and the rectosigmoid colon, resulting in partial obliteration of the cul-de-sac. Bilateral ovarian endometriomas were identified, measuring approximately 3×2 cm on the right and 4×4 cm on the left. The right ovary was adherent to the ovarian fossa and posterior uterine corpus. The left fallopian tube was markedly dilated, consistent with hydrosalpinx, with fimbrial obliteration and dense adhesions to the ovarian fossa and posterior uterus. A nodular lesion involving the posterior compartment was compatible with deep infiltrating endometriosis (Figure 2). Laparoscopic adhesiolysis was first performed to restore pelvic anatomy. A left salpingectomy was subsequently undertaken because of severe hydrosalpinx with fimbrial obliteration. Given the patient’s strong desire for future fertility, laparoscopic adenomyomectomy was performed after intramyometrial vasopressin injection, with excision of the dominant posterior adenomyotic lesion followed by multilayer uterine reconstruction using barbed sutures. Bilateral ovarian cystectomy was then completed. Chromopertubation demonstrated free spill through the right fallopian tube, indicating preserved tubal patency. Histopathological examination of the surgical specimens confirmed adenomyosis, characterized by endometrial glands and endometrial stroma embedded within bundles of hypertrophic myometrium. The ovarian cyst was consistent with an endometriotic cyst, demonstrating endometrial glands and stroma with hemosiderin pigment and hemosiderin-laden macrophages. Examination of the fallopian tube identified a paratubal cyst with mild chronic inflammatory cell infiltration without evidence of malignancy. No separate histopathological specimen from the posterior compartment lesion was submitted; therefore, the diagnosis of deep infiltrating endometriosis was established based on the concordance between preoperative imaging and intraoperative findings. Based on the documented operative findings, including bilateral ovarian endometriomas, extensive posterior compartment adhesions with partial cul-de-sac obliteration, and left tubal involvement, the disease was classified as revised American Society for Reproductive Medicine (rASRM) stage IV endometriosis. The reconstructed estimated rASRM score is presented in Table 2. | Table 2 Estimated rASRM Score Based on Documented Intraoperative Findings | The postoperative course was uneventful. The patient was discharged in stable condition and prescribed dienogest 2 mg once daily for postoperative hormonal suppression while awaiting future fertility treatment. She was counseled regarding future reproductive planning, including the possibility of assisted reproductive technologies, such as intrauterine insemination (IUI) or in vitro fertilization (IVF), depending on subsequent fertility evaluation.

The present case illustrates an increasingly recognized phenotype of diffuse adenomyosis coexisting with advanced endometriosis in a young woman. Although adenomyosis has traditionally been regarded as a disease affecting multiparous women in later reproductive life, improvements in imaging have demonstrated that it may occur considerably earlier and frequently coexist with endometriosis. Recent evidence suggests that these disorders share overlapping hormonal, inflammatory, and molecular mechanisms, supporting the concept that they represent different manifestations of a common disease continuum rather than distinct pathological entities. In this patient, diffuse adenomyosis was diagnosed preoperatively using standardized transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), confirmed histopathologically, and accompanied by surgically confirmed revised American Society for Reproductive Medicine (rASRM) stage IV endometriosis. Collectively, these findings emphasize three clinically relevant messages: adenomyosis should not be excluded solely because of young age; severe dysmenorrhea warrants early evaluation regardless of patient age; and multimodal imaging should be interpreted in conjunction with surgical findings to optimize management in women desiring future fertility.1–6,8 The coexistence of adenomyosis and deep infiltrating endometriosis (DIE) has stimulated considerable interest regarding their underlying pathogenesis. Two principal mechanisms have been proposed. The tissue injury and repair (TIAR) hypothesis suggests that repeated hormonal and mechanical injury at the endometrial–myometrial interface disrupts the junctional zone, allowing invagination of the basal endometrium into the myometrium and subsequent development of adenomyosis.2,3 In contrast, the outside-to-inside hypothesis proposes that endometriotic implants originating from the peritoneal cavity progressively infiltrate the uterine serosa and outer myometrium, eventually giving rise to adenomyotic lesions.4 Although both mechanisms may contribute to disease development, the anatomical distribution observed in the present case appears more consistent with the outside-to-inside hypothesis. Diffuse adenomyosis predominantly involved the posterior uterine wall on both TVUS and MRI, while TVUS identified a posterior compartment lesion suspicious for DIE. Laparoscopy subsequently confirmed dense adhesions between the posterior uterus and rectosigmoid colon with partial obliteration of the cul-de-sac, placing extensive posterior compartment disease immediately adjacent to the region of adenomyosis. Although this observation cannot establish causality, the close anatomical relationship between posterior DIE and posterior adenomyosis supports previous reports suggesting that these lesions may represent different stages of a shared pathological process rather than independent diseases.1–4 Another notable aspect of this case is the advanced extent of disease despite the patient’s young age. Several epidemiological studies have demonstrated that women with affected first-degree relatives have a substantially increased lifetime risk of endometriosis, highlighting the contribution of shared genetic susceptibility and epigenetic regulation.5 In the present case, the patient’s mother had a history of severe dysmenorrhea, raising the possibility of inherited susceptibility. More importantly, this family history may also have influenced the patient’s perception that severe menstrual pain represented a normal familial experience rather than a symptom requiring medical evaluation. Such normalization of dysmenorrhea is recognized as an important contributor to delayed diagnosis in endometriosis. Current evidence suggests that women frequently experience a diagnostic delay of approximately 7–10 years between symptom onset and definitive diagnosis, particularly during adolescence and early reproductive life when symptoms are often attributed to primary dysmenorrhea.6,8 Although the exact duration of symptoms in this patient cannot be determined retrospectively, prolonged normalization of severe dysmenorrhea likely delayed referral and specialist evaluation, allowing progression to extensive posterior compartment adhesions, bilateral ovarian endometriomas, severe tubo-ovarian distortion, and rASRM stage IV disease. These findings reinforce the importance of early assessment of persistent dysmenorrhea, particularly in young women with a positive family history of endometriosis or adenomyosis, to facilitate diagnosis before irreversible pelvic anatomical distortion develops. Accurate preoperative assessment of adenomyosis and deep infiltrating endometriosis (DIE) is essential for surgical planning, patient counseling, and fertility preservation. Current international guidelines recommend expert-performed transvaginal ultrasound (TVUS) as the first-line imaging modality for women with suspected endometriosis because of its accessibility, dynamic assessment, and high diagnostic performance, whereas magnetic resonance imaging (MRI) serves as a complementary examination when ultrasound findings are inconclusive, disease mapping is incomplete, or lesions beyond the sonographic field of view are suspected.6,7 Published evidence comparing the diagnostic performance of TVUS and MRI is summarized in Table 3. | Table 3 Summary of Comparative Studies Evaluating Transvaginal Ultrasound and Magnetic Resonance Imaging for Deep Infiltrating Endometriosis | Overall, comparative studies demonstrate that TVUS and MRI provide comparable diagnostic performance for ovarian endometriomas and deep infiltrating endometriosis, with neither modality consistently demonstrating overall superiority. Instead, diagnostic performance depends on lesion location, disease extent, and operator expertise. Several studies have reported that expert-performed TVUS achieves sensitivity and specificity comparable to MRI for detecting DIE and may outperform MRI in identifying posterior compartment disease, pouch of Douglas obliteration, and pelvic adhesions through dynamic assessment of organ mobility. Conversely, MRI offers superior soft-tissue contrast and comprehensive pelvic mapping, making it particularly valuable for evaluating multifocal disease, anterior compartment involvement, and complex preoperative surgical planning.7,9–17 The present case closely reflects these complementary characteristics. TVUS accurately demonstrated diffuse adenomyosis according to the Morphological Uterus Sonographic Assessment (MUSA) criteria, bilateral ovarian endometriomas, a posterior compartment lesion suspicious for deep infiltrating endometriosis (DIE), and a negative sliding sign suggesting posterior compartment adhesions. These posterior compartment findings were subsequently confirmed during laparoscopy. MRI confirmed diffuse adenomyosis through posterior junctional zone thickening with multiple intramyometrial foci and accurately characterized the bilateral adnexal lesions. In this case, TVUS provided superior assessment of posterior compartment disease, whereas MRI primarily delineated uterine and adnexal pathology. Importantly, this difference should not be interpreted as a diagnostic failure of MRI but rather as a reflection of the complementary strengths of the two imaging modalities. Unlike MRI, which provides static anatomical assessment, TVUS allows real-time dynamic evaluation of pelvic organ mobility. Assessment of the sliding sign enables indirect identification of adhesions and obliteration of the pouch of Douglas, findings that cannot be directly evaluated using conventional MRI. Consequently, subtle fibrotic adhesions and early posterior compartment fixation may remain occult on MRI despite otherwise excellent anatomical visualization. In the present case, the negative sliding sign accurately predicted dense posterior compartment adhesions that were subsequently confirmed laparoscopically, illustrating the additional diagnostic value of dynamic ultrasound. These findings are consistent with published comparative studies and reinforce the complementary rather than competitive roles of TVUS and MRI in the preoperative evaluation of advanced endometriosis. Therefore, when imaging findings are discordant but clinical suspicion remains high, laparoscopic assessment should remain the reference standard for definitive diagnosis and treatment planning.6,7,9–17 Histopathological examination confirmed both adenomyosis and ovarian endometrioma, supporting the preoperative imaging and intraoperative diagnoses. The tubal specimen demonstrated a paratubal cyst with mild chronic inflammatory cell infiltration without evidence of malignancy. Although the gross intraoperative appearance was consistent with severe hydrosalpinx, the histopathological findings reflected only the submitted specimen and therefore should not be interpreted as contradictory. Gross surgical assessment represents the overall morphology of the tubo-ovarian complex, whereas histopathological examination is limited to the tissue submitted for microscopic evaluation. In advanced endometriosis, chronic inflammation, fibrosis, and distortion of normal pelvic anatomy frequently complicate direct clinicopathological correlation. Accordingly, imaging, operative findings, and histopathology should be interpreted collectively to achieve the most accurate diagnosis.1–4 The coexistence of diffuse adenomyosis and rASRM stage IV endometriosis in a 22-year-old woman has important implications for future reproductive potential. In the present case, bilateral ovarian endometriomas, severe posterior compartment adhesions, tubo-ovarian distortion, and left hydrosalpinx requiring salpingectomy indicated advanced pelvic disease despite the patient’s young age. These anatomical abnormalities may impair natural fertility, while adenomyosis involving the junctional zone has been associated with reduced endometrial receptivity and impaired reproductive outcomes.1,2,18 Because the patient desired future pregnancy, fertility-preserving laparoscopic surgery consisting of adenomyomectomy, bilateral ovarian cystectomy, adhesiolysis, and unilateral salpingectomy was performed. This case therefore highlights the importance of early recognition of persistent dysmenorrhea and timely referral for expert imaging before progression to advanced disease compromises reproductive potential. Because the patient strongly desired future fertility, conservative surgery was selected. Fertility-preserving adenomyomectomy has evolved considerably over recent years, with increasing emphasis on individualized patient selection, meticulous multilayer uterine reconstruction, and postoperative hormonal suppression to optimize symptom control and reproductive outcomes. Although diffuse adenomyosis remains technically challenging to excise completely, conservative surgery may provide symptomatic improvement in carefully selected young women wishing to preserve fertility.20,21 The principal strength of this report is the comprehensive clinicoradiological correlation achieved through standardized TVUS using MUSA criteria, MRI, laparoscopic assessment, and histopathological confirmation of adenomyosis and ovarian endometrioma. Furthermore, integration of published comparative studies (Table 3) places the observed imaging discrepancy within the context of current evidence and provides practical guidance for interpreting discordant imaging findings in women with suspected advanced endometriosis. Several limitations should also be acknowledged. As a single case report, the findings cannot establish causal relationships between posterior DIE and adenomyosis or determine the superiority of one imaging modality over another. In addition, histopathological confirmation of the posterior compartment lesion was unavailable because no separate specimen was submitted for pathological examination. Nevertheless, the concordance between clinical presentation, multimodal imaging, and laparoscopic findings provides a comprehensive illustration of the diagnostic challenges encountered in young women with coexisting adenomyosis and advanced endometriosis.

This case demonstrates that diffuse adenomyosis can coexist with rASRM stage IV endometriosis in young women and should be considered in patients presenting with persistent dysmenorrhea regardless of age. The close anatomical relationship between posterior adenomyosis and posterior deep infiltrating endometriosis provides clinical support for the outside-to-inside pathogenic hypothesis. The discrepancy between transvaginal ultrasound and magnetic resonance imaging highlights the complementary roles of multimodal imaging, with laparoscopy remaining the reference standard when imaging findings are discordant. Early recognition of persistent dysmenorrhea, prompt referral to specialist care, and comprehensive multimodal imaging assessment are essential to facilitate timely fertility-preserving management before progression to advanced pelvic disease. Ethical Approval This study is exempted from an ethical approval as determined by the institutional and department review board. Informed Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient was informed about the nature of the publication, and all personal identifiers have been removed to ensure confidentiality and anonymity. Acknowledgment This publication charge is funded by Unpad through the Indonesian Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under the EQUITY Program (Contract No. 4303/ B3/DT.03.08/2025 and 3927/UN6. RKT/HK.07.00/2025). Author Contributions All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work. Funding The study did not receive external funding. Disclosure The authors declare that they have no competing interests.

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Ultra-minimally invasive surgery in gynecological patients: a review of the literature. Updates Surg. 2022;74(3):843–855. doi:10.1007/s13304-022-01248-y © 2026 The Author(s). This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms and incorporate the Creative Commons Attribution - Non Commercial (unported, 4.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms. 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