22 Figure 1.2: Examples of adenomyosis subtypes, A. Adenomyosis of the inner myometrium of the posterior wall (AIM), B. (Focal) Adenomyosis of the outer myometrium (FAOM) on the anterior wall, in continuum with an endometriosis lesion of the bladder. (Images taken from own study populations). Diagnosing adenomyosis Accurate adenomyosis diagnosis remains challenging as there is no consensus on diagnostic criteria, and it often differs between regions, hospitals and clinicians (19). In the associated condition endometriosis, it is known that the diagnostic delay is an average of nine years (20,21). It is unknown how long this is for adenomyosis, but it is likely to be similar, if not longer. Another element of the disease that impedes easy diagnosis is the fact that adenomyosis often coexists with other (benign) diseases; namely leiomyomas and endometriosis. Leiomyomas particularly can hamper accurate diagnosis as they are much easier to recognise on various imaging techniques (and thus may distract from adenomyosis lesions), and also are associated with similar clinical symptoms (22–24). In fact, concomitant leiomyomas are reported in up to 50% of adenomyosis patients (25). Similarly, adenomyosis and endometriosis are also often found together, with adenomyosis sometimes being referred to as ‘endometriosis interna’. Opinions are divided as to if adenomyosis and endometriosis are separate diseases, or subtypes of the same disease (8,10,19,26).
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