269 Introduction: Adenomyosis is a uterine condition closely linked to endometriosis, characterized by myometrial invasion of endometrial tissue. It is associated with dysmenorrhea, abnormal uterine bleeding, and chronic pelvic pain. Further evidence is gathering which identifies it as a cause for adverse reproductive outcomes (81,88,281). Its prevalence is debated, with some estimates as high as 20% of women in the fertile phase of life (7). While most studies have investigated the relationship between adenomyosis and fertility, recent literature also proposes that presence of adenomyosis may lead to a higher risk of obstetric complications such as preterm birth (PTB), foetal growth restriction (FGR) and hypertensive disorders of pregnancy (HDP) (103–105,108) . Elements of the pathophysiology of adenomyosis – namely its disruption of the uterine junctional zone and thereby uterine contractility – have been hypothesized to influence the obstetric function of the uterus. HDP are thought to arise from impaired spiral artery development and placentation in this same junctional zone. Furthermore, the junctional zone has an important role in uterine contractile function (111,259,285), which is arguably most well-known in the onset and progress of labour. Common obstetric complications such as failure to progress, uterine hyperstimulation and atony, and placental retention are likewise associated with aberrant uterine contractility. Part of the problem in gaining consensus regarding the (obstetric) consequences of adenomyosis lies in its diagnosis in the first place. Adenomyosis is often underdiagnosed due up to one third of women remaining asymptomatic (or not consulting a gynaecologist for their symptoms), alongside a lack of uniform diagnostic criteria (19,182). Whilst adenomyosis can be relatively accurately diagnosed using imaging techniques such as transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), the diagnostic criteria vary, and there is a high level of inter-observer variability (29,31–34,181,192). For this reason, the gold standard for adenomyosis diagnosis remains histopathology. With biopsy also not being sufficiently accurate (286), adenomyosis is most reliably diagnosed after hysterectomy in women after having completed their childbearing wish. This poses a clinical challenge as it is now commonly accepted that adenomyosis may be highly prevalent in younger, nulliparous women (7,19,78,287).
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