Heavy menstrual bleeding is a common reason for gynecological consultation and can substantially affect a woman’s physical, emotional, social and occupational well-being. Persistent excessive menstrual blood loss may result in iron deficiency and anemia, fatigue, reduced productivity and impaired quality of life. Although uterine leiomyomas, endometrial polyps and ovulatory dysfunction are frequently considered during the evaluation of abnormal uterine bleeding, adenomyosis is another important structural cause that may remain unrecognized.

Adenomyosis is a benign gynecological condition characterized by the presence of endometrial glands and stroma within the myometrium, often accompanied by surrounding smooth-muscle hypertrophy and hyperplasia. Historically, diagnosis was commonly established through histopathological examination of hysterectomy specimens, which contributed to the perception that the condition mainly affected older, multiparous women. The wider use of transvaginal ultrasonography and magnetic resonance imaging has demonstrated that adenomyosis can also be identified in younger women and in patients who have not undergone hysterectomy [1–3].

The pathogenesis of adenomyosis is complex and is not completely understood. Proposed mechanisms include invagination of the endometrial basalis into the myometrium, tissue injury and repair at the endometrial–myometrial interface, altered uterine peristalsis, local estrogen activity, progesterone resistance and inflammatory changes. These processes may alter myometrial architecture and uterine contractility and contribute to heavy menstrual bleeding, dysmenorrhea and chronic pelvic pain [4–6].

Heavy menstrual bleeding is one of the most clinically important presentations of adenomyosis. Women may report excessive flow, prolonged periods, passage of blood clots and painful menstruation. Symptoms are not specific, however, and may overlap with uterine fibroids, endometriosis and other causes of abnormal uterine bleeding. Some women may normalize heavy periods or delay seeking care, while clinicians may initially attribute symptoms to hormonal disturbances or other structural abnormalities. These factors can contribute to delayed recognition and prolonged symptom burden [2,7].

Transvaginal ultrasonography is generally used as the first-line imaging investigation for suspected adenomyosis. The revised Morphological Uterus Sonographic Assessment (MUSA) consensus describes direct features, including myometrial cysts, hyperechogenic islands and echogenic subendometrial lines or buds, and indirect features, including globular uterine configuration, asymmetric myometrial thickening, fan-shaped shadowing, translesional vascularity and an irregular or interrupted junctional zone. MRI can provide additional anatomical information when ultrasound findings are inconclusive or detailed mapping is required [8–11].

Management is individualized according to symptom severity, age, comorbidities and reproductive plans. Medical options include non-steroidal anti-inflammatory drugs, tranexamic acid, progestins, combined hormonal contraception, the levonorgestrel-releasing intrauterine system and gonadotropin-releasing hormone analogues. Uterine-sparing procedures may be considered in selected patients, while hysterectomy remains a definitive option for women who do not desire future pregnancy and have persistent symptoms despite conservative treatment [12–15].

Despite advances in imaging, adenomyosis may be overlooked in women presenting with heavy menstrual bleeding, particularly when the ultrasound assessment does not specifically evaluate the myometrium. Local hospital-based evidence can help describe the clinical profile of affected women and emphasize the importance of appropriate imaging. The present study was therefore conducted at PAF Hospital to determine the frequency of sonographically suspected adenomyosis among women presenting with heavy menstrual bleeding and to describe associated demographic characteristics, clinical symptoms and ultrasonographic findings.

A descriptive cross-sectional study was conducted at PAF Hospital, Pakistan, over six months, from 15 March 2026 to 14 September 2026. A total of 90 women presenting with heavy menstrual bleeding to the gynecology outpatient department were included. Non-probability consecutive sampling was used to recruit eligible participants until the required sample size was achieved. Women of reproductive age presenting with excessive menstrual blood loss, prolonged menstrual bleeding or passage of blood clots were eligible for inclusion. Pregnant and postmenopausal women, patients with a history of hysterectomy, known gynecological malignancy, or those unwilling to provide informed consent were excluded. After written informed consent, demographic and clinical information was collected using a structured proforma. Variables included age, body mass index, marital status, parity, reproductive history, menstrual duration and pattern, severity of bleeding, dysmenorrhea, pelvic pain, passage of blood clots and previous gynecological history. Participants underwent pelvic ultrasonography, preferably transvaginal ultrasonography; transabdominal ultrasonography was considered when transvaginal examination was unsuitable or declined. The assessment included uterine size and morphology, globular configuration, asymmetric myometrial thickening, myometrial cysts, hyperechogenic islands, fan-shaped shadowing and junctional-zone abnormalities. Sonographic findings were assessed with reference to the revised MUSA terminology. . Adenomyosis was diagnosed on sonographic criteria alone; histopathological confirmation was not performed, and cases are therefore described as sonographically suspected adenomyosis. Data were analyzed using IBM SPSS Statistics version 27. Categorical variables were summarized as frequencies and percentages, while continuous variables were expressed as mean and standard deviation or median and interquartile range according to distribution. Associations between adenomyosis and selected clinical characteristics were assessed using the Chi-square test or Fisher’s exact test, as appropriate [verify against the original dataset and state the test(s) actually used]. A p-value below 0.05 was considered statistically significant. The study was approved by the [name of Ethics Committee], PAF Hospital, Participant confidentiality was maintained.

A total of 90 women presenting with heavy menstrual bleeding were included.

Demographic characteristics

Table 1. Demographic characteristics of study participants (n=90)

The mean age of participants was 36.8 ± 7.2 years. The largest age group was 31–40 years (42.2%). Multiparous women constituted 75.6% of the study population. Overweight and obesity were recorded in 43.3% and 30.0% of participants, respectively (Table 1).

Frequency of adenomyosis

Table 2. Frequency of ultrasonographically suspected adenomyosis (n=90)

Ultrasonographic features suggestive of adenomyosis were identified in 36 (40.0%) participants, while 54 (60.0%) had no sonographic evidence of adenomyosis (Table 2).

Clinical characteristics

Table 3. Clinical characteristics of participants (n=90)

Multiple responses were allowed; percentages therefore do not total 100%.

Passage of blood clots was the most frequently reported symptom (61.1%), followed by dysmenorrhea (57.8%) and prolonged menstrual bleeding (52.2%) (Table 3).

Ultrasonographic features

Table 4. Ultrasonographic features among participants with suspected adenomyosis (n=36)

Multiple features could be present in an individual participant.

Globular uterine configuration was the most frequently documented feature (61.1%), followed by asymmetric myometrial thickening (55.6%) and myometrial cysts (50.0%) (Table 4, Figure 1).

Figure 1. Distribution of ultrasonographic features among the 36 participants with sonographic features of adenomyosis.

Association with symptoms

Table 5. Association between sonographically suspected adenomyosis and selected clinical characteristics (n=90)

Pearson’s Chi-square test; p<0.05 was considered statistically significant.

The three clinical characteristics are compared between participants with and without sonographic features of adenomyosis in Table 5 and Figure 2.

Figure 2. Comparison of dysmenorrhea, prolonged menstrual bleeding and pelvic pain between participants with and without sonographic features of adenomyosis.

The present study evaluated sonographically suspected adenomyosis among women presenting with heavy menstrual bleeding at PAF Hospital. 36 (40.0%) of 90 participants had ultrasonographic features suggestive of adenomyosis. This finding indicates that adenomyosis is an important diagnostic consideration in women attending gynecological services with excessive menstrual blood loss. The frequency observed in this study is within the broad range reported among symptomatic women, although estimates vary substantially according to the population studied and the diagnostic method used. Upson and Missmer described the epidemiological challenges of adenomyosis, including differences in case ascertainment and the historical reliance on hysterectomy specimens [1]. Recent evidence also indicates that prevalence estimates from symptomatic or referral-based cohorts should not be directly compared with estimates from general populations [2]. Differences in referral patterns, ultrasound expertise and diagnostic thresholds may explain variation between studies. In this study, women aged 31–40 years formed the largest age group, and multiparous women represented most participants. Adenomyosis has traditionally been associated with later reproductive age and multiparity, but contemporary imaging has demonstrated that the disease can also occur in younger and nulliparous women. Age and parity should therefore be considered clinical characteristics rather than diagnostic requirements or proof of causation [1,2]. The cross-sectional design does not allow the present study to establish whether parity independently increases the risk of adenomyosis. Dysmenorrhea was more frequently reported among participants with adenomyosis than among those without sonographic evidence of the condition. This is consistent with the recognized clinical presentation of adenomyosis, which commonly includes heavy menstrual bleeding, painful menstruation and chronic pelvic pain [2,9]. Proposed mechanisms include local inflammatory activity, altered uterine contractility and changes in myometrial architecture. However, these symptoms are not specific to adenomyosis and may also occur with endometriosis, leiomyomas and other gynecological disorders. Prolonged menstrual bleeding and pelvic pain were also more frequent in the adenomyosis group in the provisional results. These findings support the importance of taking a detailed menstrual and pain history in women presenting with heavy menstrual bleeding. The combination of excessive bleeding and dysmenorrhea may raise clinical suspicion, but the absence of pain does not exclude adenomyosis. Assessment should also consider coexisting structural and non-structural causes of abnormal uterine bleeding. Globular uterine configuration and asymmetric myometrial thickening were the most frequently recorded sonographic findings, while myometrial cysts were the most common direct feature. The revised MUSA consensus distinguishes direct features, which indicate ectopic endometrial tissue within the myometrium, from indirect features reflecting secondary myometrial changes [8,9]. This distinction is clinically important because indirect features alone should be interpreted cautiously. Standardized reporting may improve communication between sonographers and gynecologists, although reproducibility and operator experience remain relevant limitations. Transvaginal ultrasonography is an appropriate first-line investigation for suspected adenomyosis because it is widely available and allows assessment of the myometrium and junctional zone. MRI may be useful when ultrasound findings are inconclusive, when coexisting pelvic pathology is suspected, or when detailed anatomical mapping is needed [7,11]. The diagnosis in this study was based on imaging rather than histopathology; therefore, the results should be described as sonographically suspected adenomyosis unless histological confirmation was available. Recognition of adenomyosis is important because treatment can be individualized according to symptoms, age and reproductive plans. Medical options include tranexamic acid, non-steroidal anti-inflammatory drugs, progestins, the levonorgestrel-releasing intrauterine system and gonadotropin-releasing hormone analogues. Uterine-sparing interventions may be considered in selected patients, while hysterectomy remains definitive for women who have completed childbearing and have persistent symptoms despite conservative management [7,12]. Women who desire pregnancy may require counselling regarding the possible association of adenomyosis with reproductive and obstetric outcomes [14]. The study has several limitations. It was conducted at a single hospital and included a relatively small sample of 90 women, which may limit generalizability. The cross-sectional design does not establish temporal or causal relationships. Ultrasound-based diagnosis without histopathological confirmation may lead to diagnostic misclassification, and coexisting fibroids or endometriosis may influence symptoms. In addition, the numerical dataset currently presented is provisional and must be replaced with verified patient-level data. Future multicenter studies using standardized imaging criteria and clearly defined diagnostic thresholds are recommended.

Adenomyosis is an important and potentially under-recognized cause of heavy menstrual bleeding among women attending gynecological services. In the study results, sonographic features of adenomyosis were identified in 40.0% of participants. Dysmenorrhea, prolonged menstrual bleeding and pelvic pain were more frequently reported among women with sonographic features of adenomyosis. Globular uterine configuration, asymmetric myometrial thickening and myometrial cysts were common imaging findings. These observations underline the importance of considering adenomyosis during the assessment of women presenting with excessive menstrual blood loss. A detailed menstrual history combined with standardized pelvic ultrasonography may facilitate recognition and support individualized management.

Recommendations

Adenomyosis should be considered in women presenting with heavy menstrual bleeding, particularly when excessive blood loss is accompanied by dysmenorrhea, prolonged periods or pelvic pain. Gynecologists and sonographers should ensure that pelvic ultrasound examinations include a deliberate assessment of the myometrium and document direct and indirect features using the revised MUSA terminology. Women with persistent symptoms should receive an individualized assessment, including evaluation for anemia and coexisting uterine or pelvic pathology, and treatment should be selected according to symptom severity and reproductive intentions. Training in standardized ultrasound assessment and increased awareness among healthcare professionals may reduce missed or delayed diagnoses. Larger multicenter studies in Pakistani populations are recommended to provide more representative estimates and evaluate the clinical utility of imaging-based diagnostic criteria.

Authors’ Contributions

Dr. Shehnaz Sheeba contributed to the conceptualization and design of the study, supervised the clinical assessment and patient recruitment, guided the interpretation of the findings, and critically revised the manuscript for important intellectual content. Dr. Fatima Habib contributed to patient recruitment, clinical assessment, data collection, literature review, and drafting and revision of the manuscript. Dr. Qandeel Rasheed contributed to patient recruitment, clinical data collection, assessment of ultrasound findings, data organization, and review of the manuscript. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.