When should I consider referring a patient with adenomyosis for specialist evaluation or surgical intervention?

You should consider referring a patient with adenomyosis for specialist evaluation or surgical intervention in the following circumstances:

• Persistent Symptoms Despite Initial Management: If a patient's heavy menstrual bleeding (HMB) symptoms persist despite initial pharmacological treatment, further investigation or specialist input may be required ¹. Similarly, if pain, which can be associated with HMB and potentially caused by adenomyosis or endometriosis, does not respond adequately to a trial of first-line analgesics (such as paracetamol or NSAIDs), referral for further assessment should be considered ¹,².
• Suspicion Requiring Specialist Investigation: If a patient presents with significant dysmenorrhoea (period pain) or a bulky, tender uterus on examination, suggesting adenomyosis, a transvaginal ultrasound should be offered as the preferred investigation ¹. While this is a diagnostic step, it often precedes specialist evaluation for management options.
• Consideration of Surgical Intervention: Surgical options for HMB, such as hysterectomy or endometrial ablation, are specialist procedures ¹. Referral for specialist consultation is appropriate when these interventions are being considered, particularly if medical management has been unsuccessful or is unsuitable ¹. A full discussion about the implications of surgery, including impact on fertility, sexual feelings, and bladder function, should occur before a decision is made ¹.