I have two patients with a small age difference. One was 38 years old and the other 41 years old, both at the busiest time in their families and careers. 38 years old patient had severe menstrual cramps every time she had her period. She was always bedridden for 3 days during her menstrual period, and the pain was excruciating, and her periods were particularly heavy. The whole family was in great pain during the days of menstruation. Even daily chores and taking my daughter to and from school became a luxury, not to mention going to work and going out. In the end, I had to rely on medication to stop the pain. She once asked me to remove her uterus, which was such a helpless choice. Another patient of mine was also suffering from unbearable menstrual pain. Her main symptoms were: pain before menstruation for 1 day, pain during menstruation for 3 days, and pain after menstruation for 6-7 days. These two patients of mine, although their symptoms were somewhat different, suffered from the same disease – adenomyosis. Why is there such severe pain during menstruation? Adenomyosis, in layman’s terms, is a “problem” with the muscles and glands of the uterus. The uterus is made up of three layers of tissue: the innermost is the endometrium, the middle is the muscle, and the outer layer is the plasma membrane, which is the same as the peritoneum. Normally, the endometrium should be below the muscle layer and there is a boundary between them. If the endometrium and the superficial muscular layer are damaged, such as during childbirth, multiple abortions and scrapings, the endometrium will “enter” and grow into the muscular layer. The endometrium in the muscle can, like the normal endometrium, become periodically engorged, edematous and even bleeding with the menstrual cycle, causing strong uterine contractions and severe lower abdominal pain (Figure 1). Figure 1 Adenomyosis Symptoms exhibited by adenomyosis The first two patients had very typical symptoms. In adenomyosis, excessive menstruation and progressive dysmenorrhea are the main manifestations. The symptoms are mainly persistent lower abdominal pain, lumbar pain, anal cramping with nausea and vomiting. This disease often leads to infertility or anemia. The pronounced pain often occurs in older women, i.e. when they approach 40 years of age, and the dysmenorrhea gradually worsens, often spasmodically. The typical clinical course is the onset of small abdominal pains during menstruation, which usually become increasingly severe. Pain medication is usually required, and many patients require pain injections. Some women are in so much pain that they roll around on the floor, and the pain relief injections do not completely stop the pain. Over time, the pain relief injections become less and less effective, so that they cannot keep up with their daily routine. Even more unfortunately, adenomyosis has the added problem of infertility. This is especially painful in younger women. Not only do they suffer from unspeakable pain every month, but they also suffer from infertility and are physically and emotionally exhausted from seeking medical help. Adenomyosis is diagnosed in middle-aged women of childbearing age with secondary, progressively increasing dysmenorrhea, which should be considered as adenomyosis. Adenomyosis should also be considered if it is accompanied by excessive menstruation, prolonged periods and an enlarged uterus. A careful gynecologic examination, ultrasound, and MRI can help with the diagnosis. Can a patient with adenomyosis get pregnant? Adenomyosis often occurs in women between the ages of 30 and 50. Usually this group of patients have mostly completed their reproductive tasks and do not have to worry about infertility. However, in recent years, there has been a significant increase in the number of young people in their 20s and women over the age of 30 who have not yet had children. This is a very difficult problem in clinical practice. Once adenomyosis is developed, the most important concern of young patients is whether they will be infertile? It is generally believed that severe adenomyosis, especially when combined with endometriosis, can lead to infertility. This type of patient has a thick uterus and is prone to complications such as pelvic adhesions, which are not conducive to ovulation and embryo implantation, resulting in a low natural pregnancy rate. Fortunately, it is not uncommon for young women to have severe adenomyosis. In cases of mild adenomyosis, there is still a chance to get pregnant. Effective treatment for adenomyosis For obstetricians and gynecologists, we choose either medication or surgery, depending on the patient’s condition. For young patients with fertility needs conservative treatment or conservative surgery is the first priority to try to preserve the uterus. There are many options for drug treatment, such as analgesics, oral contraceptives, and GnRHa (natural gonadotropin-releasing hormone) drugs, which are mainly used to relieve symptoms. In recent years, the intrauterine device (IUD) with extended-release levonorgestrel (trade name, Manuelle), which is used clinically, can significantly improve symptoms such as dysmenorrhea and pelvic pain and excessive menstruation in patients with adenomyosis, providing a good option for such patients (Figure 2). Fig. 2 Mannedrol – IUD for adenomyosis This is a special intrauterine device containing progestin and releasing drugs at a quantitative and constant daily rate, which acts as a treatment. For surgical treatment, excision of the adenomyosis lesion is indicated for young patients who require preservation of the uterus. It is a constructive procedure aimed at improving symptoms, increasing the chances of pregnancy, or dispensing with the host of problems associated with hysterectomy. However, because recurrence is a prominent problem, postoperative medication to prevent recurrence is an issue that cannot be ignored. One should not assume that the surgery is over, and I often instruct patients to follow up regularly. Total hysterectomy is a devastating procedure for older patients without fertility requirements, but the efficacy is reliable.