Endometriosis and adenomyosis: diagnosis and management

SUMMARY

Endometriosis and adenomyosis are common chronic gynaecological conditions with significant health and economic impacts.

Endometriosis and adenomyosis present with diverse and overlapping symptoms and can coexist. Symptoms may include pelvic pain, dysmenorrhoea, heavy menstrual bleeding, fatigue and subfertility, contributing to impaired quality of life and reduced participation in work, education and social activities.

General practitioners are often the first point of contact and play a critical role in early recognition, preliminary diagnosis, initiation of treatment and referral.

The current Australian guideline supports clinical diagnosis and early management without waiting for surgical confirmation. First-line management includes analgesia and hormonal therapies, tailored to patient priorities, goals, fertility intention, comorbidities and concomitant medications.

Timely investigation, person-centred care and appropriate referral are essential to reducing diagnostic delay, symptom burden and long-term impacts.

 

Introduction

Endometriosis and adenomyosis are chronic conditions characterised by the presence of endometrial-like tissue outside its normal location, affecting individuals assigned female at birth (henceforth referred to as ‘women’).

Endometriosis occurs when endometrial-like tissue grows outside the uterus, mainly on pelvic organs and tissues,¹ and is now understood as a chronic systemic disease that extends beyond the pelvic organs and tissues.² Adenomyosis occurs when endometrial tissue grows within the muscle layer of the uterus³ and can occur with or without endometriosis.⁴ Both conditions have varied clinical presentations and are under-recognised.⁴

A key advancement in endometriosis and adenomyosis care, reflected in the recently updated Australian Living Evidence Guideline: Endometriosis (the guideline),⁴ is the shift towards nonsurgical diagnostic approaches, enabling earlier diagnosis and management.

General practitioners (GPs) play a key role in initiating treatment, ongoing management and facilitating self-management of these chronic conditions. In addition, the Australian Government has committed to better health outcomes through funding the Endometriosis Management Plan released nationally in September 2026, which aims to support the diagnosis and management of endometriosis and pelvic pain in general practice.⁵

 

Epidemiology

Epidemiology of endometriosis

In Australia, 14% of women will be diagnosed with endometriosis by the age of 48 years,⁶ and many women have suspected endometriosis without a formal diagnosis. Although diagnosis has previously been described as taking approximately 8 years from symptom onset,⁷ recent analysis of Australian general practice data suggests this might be decreasing.⁸ The cause of endometriosis is uncertain, but those with a family history of endometriosis appear to be at greater risk.⁹

Endometriosis is an estrogen-dependent condition, with symptoms typically improving after natural menopause. However, premature menopause is not uncommon in this population, often resulting from surgical management such as bilateral oophorectomy, and carries significant morbidity, long-term health risks and economic burden.¹⁰ Persistent or recurrent disease after menopause is uncommon but has been reported, particularly in association with menopausal hormone therapy and other forms of exogenous estrogen exposure.¹¹

Endometriosis has significant adverse impacts on women’s lives, including on their physical and mental health, fertility, relationships and ability to engage in study, employment and social activities.¹² The annual economic burden of endometriosis and pelvic pain in Australia is estimated to be up to A$9.36 billion, or approximately A$24,437 to $30,093 per woman per year.¹³ In 2025, the World Economic Forum identified endometriosis as 1 of 9 health conditions most significantly affecting women’s lives, their communities and the global economy.¹⁴

Epidemiology of adenomyosis

Adenomyosis is thought to be common in women of reproductive age.¹⁵ However, its true prevalence is difficult to establish due to the wide range in severity of symptoms and different diagnostic modalities (histological and imaging).¹⁵ Approximately 30% of women who are diagnosed with adenomyosis report no symptoms.¹⁶ A 2023 review found a 19% prevalence among women with subfertility in Australia.¹⁷ Disruptions to the endomyometrial junction (e.g. due to pregnancy or uterine surgery) may increase the risk of adenomyosis.^4,18

There is limited research on the prevalence and impact of adenomyosis.¹⁸ Small studies indicate significant symptom burden, similar to endometriosis, with impacts on participation in work and school, social and personal relationships and physical activity, mainly due to heavy menstrual bleeding, pain and fatigue,¹⁹ as well as infertility and recurrent miscarriage.²⁰ Further work is needed to establish national data²¹ and investigate patient perspectives¹⁹ to improve understanding and management of the condition.

 

Presentation

The range of symptoms experienced in endometriosis and adenomyosis vary in severity and nature, which can make both conditions difficult to recognise.

Symptoms and signs of endometriosis

Women may present to GPs with a wide range of nonspecific symptoms, which can be overlooked or mistaken for other conditions.⁸ In a nationally representative general practice sample of 19,786 women diagnosed with endometriosis, 13,202 (66.7%) had at least one documented endometriosis-related symptom prior to diagnosis. More than half (57.6%) had 2 or more endometriosis-related symptoms. The most frequent symptoms were cyclical or persistent pelvic pain (40.8%), dysmenorrhoea (22.1%), fatigue (19.3%), heavy menstrual bleeding (15.0%) and altered bleeding (12.5%). Infertility and nonspecific symptoms, such as headaches, urinary and bowel symptoms, back pain and pain with sexual intercourse, were less common.^4,8

On examination, vaginal endometriosis lesions may be visible.⁴ Signs on pelvic examination include pelvic and vaginal tenderness, nodularity of the posterior vaginal wall and enlarged pelvic organs with reduced mobility on bimanual palpation.⁴

Symptoms and signs of adenomyosis

Women in their 40s are at highest risk of experiencing symptomatic adenomyosis.²² Although often asymptomatic, the commonest symptoms of adenomyosis are dysmenorrhoea, heavy menstrual bleeding,^3,20 pelvic pain,^15,17,20 subfertility and bladder and gastrointestinal symptoms.²⁰ Bimanual examination of the pelvis, particularly in women with gynaecological symptoms, can assess uterine or pelvic tenderness and uterine size and mobility, which may suggest the possibility of adenomyosis.²⁰

 

Diagnosis

GPs are often the first point of contact within the health system for women with endometriosis and adenomyosis symptoms.²¹ They can conduct initial symptom assessments, make preliminary diagnoses of endometriosis and adenomyosis, initiate early treatment to improve patient symptoms and provide referrals as required.

Diagnosis of endometriosis

The updated guideline recommends diagnosis based on clinical assessment, imaging and an early trial of treatment to assess response without waiting for surgical confirmation.⁴

A clinical diagnosis can be suspected when one or more of the previously mentioned symptoms or signs are present.⁴ Normal examination findings do not rule out endometriosis.⁴ Imaging can confirm a diagnosis and facilitate validation of symptoms and treatment planning.⁴

The guideline recommends transvaginal ultrasound as the first-line investigation.⁴ Transvaginal ultrasound can detect endometriosis of the pelvis and endometrioma (particularly when performed and reported by specialists trained in endometriosis) and assess for alternative causes of symptoms.⁴ However, normal ultrasound findings do not rule out endometriosis, especially superficial disease.⁴ If deep endometriosis is suspected, based on examination or transvaginal ultrasound results, or transvaginal ultrasound is not appropriate for or acceptable to the patient, pelvic magnetic resonance imaging (MRI) is recommended.⁴ MRI for this indication is Medicare funded when requested by a gynaecologist but not when requested by a GP, in which case it incurs out-of-pocket costs.⁴

Laparoscopy offers definitive diagnosis via direct visualisation and biopsy for histological confirmation,⁴ but is an invasive surgical procedure with associated risks, costs and wait times. Laparoscopy may not be required if clinical assessment and imaging results are consistent with endometriosis and there is a response to treatment. Although multiple biomarkers are being studied, there is currently no certain evidence of sufficient sensitivity and specificity to support biomarker testing in the diagnosis of endometriosis; for example, cancer antigen 125 (CA-125) has a high false negative rate for detecting endometriosis.⁴

Diagnosis of adenomyosis

The guideline recommends ultrasound (without being specific about the type of ultrasound) as the first-line investigation when adenomyosis is suspected and MRI as the second-line investigation.⁴

Historically, diagnosis of adenomyosis was histological following surgery (either laparoscopy with biopsy or hysterectomy).³ However, noninvasive diagnostic techniques, including transvaginal and transabdominal ultrasound and MRI, have improved substantially¹⁸ and are increasingly used for diagnosis³ due to their high accuracy.²³ Ultrasound may be more accessible and costs less than MRI.⁴

Classification of endometriosis and adenomyosis

There is currently no universally agreed system for the classification of either endometriosis^24,25 or adenomyosis.^26,27 Endometriosis is variously classified based on the extent and severity of the disease or predicted fertility outcomes.^24,25 Adenomyosis classification systems are based on disease severity and subtypes.^28,29

 

Management of endometriosis and adenomyosis

There are no cures for endometriosis or adenomyosis, so management is focused on symptom relief and improving quality of life.³⁰ Management should be tailored to suit the patient’s priorities, goals, fertility intention, comorbidities and current (and previous) medications, using a person-centred approach and shared decision-making.³¹ Understanding which symptoms are causing the greatest concern can help determine the patient’s priorities, such as reducing pain or preventing symptom recurrence after surgery. Understanding the broader impacts of the condition can help define goals; for example, to improve physical activity or quality of life.

Pharmacological treatment

First-line pharmacological treatments for endometriosis and adenomyosis include simple analgesia and hormonal treatments, individually or in combination.⁴ Nonsteroidal anti-inflammatory drugs (NSAIDs), with or without paracetamol, should be offered for cyclical pain symptoms, unless contraindicated. The guideline recommends trial of intermittent NSAIDs for periods of up to 7 days over 3 months, followed by GP review of the response.⁴

Opioid analgesia should only be used for postoperative or other acute pain short term and at the minimum effective dose, weighing the risks against the benefits.⁴ Regular opioid use can make the management of endometriosis-related pain more difficult.⁸

Hormonal treatments aim to reduce estrogen concentration, suppress endometrial cell growth and stop menstruation, thereby alleviating pain.^1,32 First-line hormonal treatment options for women with endometriosis who are not currently intending to conceive include the combined oral contraceptive pill, contraceptive vaginal ring, progestogen-only contraceptives (oral, depot injection, implant, intrauterine device) and oral dienogest.⁴ Intrauterine devices are first-line contraceptive options for women of all ages, including young nulliparous women.³³ Treatment choice is guided by patient preference, previous contraceptive use, symptoms, adverse effect profiles and contraindications. Response to treatment should be reviewed within 3 to 6 months of starting or changing therapy and should include the assessment of symptoms, adverse effects and suitability. If treatment response is unsatisfactory, an alternative first-line hormonal contraceptive method can be trialled.⁴

First-line hormonal treatments for women with adenomyosis who are not currently intending to conceive include oral dienogest, oral contraceptives, the levonorgestrel intrauterine device and etonogestrel implant.⁴ Response to treatment should be reviewed after 3 months of starting or changing therapy and an alternative first-line treatment or referral to a gynaecologist offered if there has not been clinical improvement.⁴

Second-line treatments for endometriosis and adenomyosis are gonadotrophin-releasing hormone (GnRH) analogues (agonists including goserelin and nafarelin and antagonists including relugolix), which require gynaecologist initiation and oversight.^4,34,35 These drugs reduce systemic estrogen concentrations with the aim of suppressing menstruation. They also induce hypoestrogenic menopause-like symptoms,¹ including adverse effects such as vasomotor symptoms, vaginal dryness³⁴ and reduced bone mineral density. For this reason, treatment with GnRH agonists is limited to 6 months,³⁵ or 2 years if combined with menopausal hormone therapy,³⁴ and comes with a caution about limiting peak bone mass in young people.

The newest GnRH antagonist, relugolix, is an oral therapy available as a combination tablet with add-back (replacement) estrogen (estradiol) and progestin (norethisterone) to reduce the risk of adverse effects, and is indicated for the treatment of endometriosis.³⁵

Although there is limited evidence regarding the use of neuromodulators (e.g. gabapentin, pregabalin, amitriptyline, nortriptyline, duloxetine, venlafaxine), they may be considered for the treatment of endometriosis- or adenomyosis-related pain. The clinician should discuss the potential benefits and harms of neuromodulators with the patient.^4,36

An antifibrinolytic medication, tranexamic acid, can be offered to treat heavy menstrual bleeding. This can be used alone or alongside hormonal treatment or NSAIDs.³⁷ However, it does not treat endometriosis lesions or underlying disease activity.

Nonpharmacological treatment

Although there is low certainty of evidence of benefit from a range of nonpharmacological treatments for endometriosis, the guideline makes conditional recommendations that may be associated with improvements in some symptoms (particularly pain) and quality of life, including pelvic physiotherapy, dietary modification, acupuncture, counselling and mindfulness practice.⁴

A chronic condition management plan and a mental health plan can assist with assessment and access to appropriate services.⁴

There is a lack of evidence to guide nonpharmacological interventions for adenomyosis.⁴

Surgical treatment

Surgical treatment for endometriosis

In general, laparoscopy is preferred to laparotomy when surgery is performed for endometriosis, and may be diagnostic or therapeutic. Excision and ablation offer equivalent benefits and harms, except in the treatment of endometriomas, where excision is recommended.⁴ It is important to carefully consider the potential benefits (little or no difference in pain and quality of life) and harms (risk of tubal and peritoneal adhesions and surgical risks) of repeat laparoscopy for endometriosis.⁴ Surgery for patients with deep infiltrating endometriosis involving the bowel, bladder or pelvic side wall should be performed by specialists with appropriate expertise.⁴ There is little evidence that hysterectomy is effective for improving patient outcomes, including pain.⁴

Surgical treatment for adenomyosis

Surgical treatment for adenomyosis is usually conservative.⁴ Removal or destruction of the uterine lining (endometrial ablation) may relieve symptoms such as heavy menstrual bleeding.⁴ Hysterectomy eliminates bleeding symptoms and the possibility of recurrence; however, chronic pain sensitisation means the pain can still exist in the absence of the original stimulus, and there is currently no evidence for or against hysterectomy improving adenomyosis-associated pain.⁴

When to refer

Referral to a pain management specialist or multidisciplinary pain service can enhance the management of chronic pelvic pain for patients with endometriosis and adenomyosis. Similarly, referral to specialist gynaecology or fertility services may be required. For example, referral to a gynaecologist with laparoscopy skills may be indicated for diagnosis if symptoms do not respond to an adequate trial of treatment or if imaging is suggestive of deep infiltrating endometriosis or extrapelvic involvement.⁴ Referral to a fertility specialist may be required when fertility is a priority and attempts to conceive have been unsuccessful (e.g. after 6 to 12 months of regular unprotected sexual intercourse).⁴ A patient may require investigatory laparoscopy before assisted reproductive treatment as part of their pretreatment planning.⁴

 

Conclusion

Endometriosis and adenomyosis are common conditions affecting Australian women and have significant health impacts. GPs can make preliminary diagnoses of endometriosis and adenomyosis, initiate treatment and make appropriate referrals. Each of these steps is an important and effective way of reducing the time to diagnosis, improving patient symptoms and reducing the overall impact and burden of these conditions on patients and the community.

 

Key practice points

 

Resources for healthcare practitioners

• Australian Living Evidence Guideline: Endometriosis – evidence-based recommendations for healthcare practitioners who diagnose and manage people with suspected or confirmed endometriosis or adenomyosis
• HealthPathways – locally agreed, evidence-based clinical guidance (access and content vary by state or region)
• Endometriosis and Pelvic Pain Clinics – a national initiative that has established clinics across Australia with at least one in every Primary Health Network region
• Endometriosis Management Plan – a nationally available evidence-based online tool that can be used to develop a tailored chronic condition management plan for patients with endometriosis or chronic pelvic pain symptoms
• EndoZone – resources for clinicians and consumers

This article was finalised on 31 August 2026.

Conflicts of interest: Danielle Mazza is a member of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists National Endometriosis Guideline Development Group. Danielle has received research funding from Bayer, Organon and Merck Sharp & Dohme (MSD), and has been on advisory boards for Bayer, Organon, MSD and Gedeon Richter. She is a member of the Therapeutic Goods Administration Women’s Health Products Working Group.

All authors are researchers at the SPHERE Centre of Research Excellence in Women’s Sexual and Reproductive Health in Primary Care, which is funded by the National Health and Medical Research Council. The authors are involved in developing resources for managing endometriosis and chronic pelvic pain.

This article is peer reviewed.

 

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