Your TVUS interpretation was 'suggestive of adenomyosis' — not diagnostic. MRI is the standard confirmatory modality and is needed to characterize whether the disease is diffuse or focal, posterior or anterior, and to plan any interventional procedure. Proceeding to hysterectomy without MRI staging contradicts the Kho 2026 workup recommendation.

Key outcome: MRI confirms diagnosis and enables proper treatment selection — focal disease has different optimal interventions than diffuse disease.

Tradeoffs: Wait time for OHIP-funded pelvic MRI in Ontario; cost ~$0 with referral but timeline 4–8 weeks.

Non-invasive, fertility-preserving, no incision, no anaesthesia in many protocols. Specifically appropriate for you since you're preserving fertility. Not clinically available in Canada for adenomyosis (Sunnybrook treats fibroids only, Profound Medical's Sonalleve is CE-marked in EU but not clinically accessible domestically) — Weill Cornell in NYC is the closest Centre offering it.

Key outcome: 53.4% pregnancy rate post-treatment, 35.2% live birth rate, 90.3% complete dysmenorrhea relief at 6 months (Chen 2024 meta-analysis, n=557). Zero uterine ruptures reported.

Tradeoffs: Cross-border self-pay (~C$20–35K all-in including travel and accommodation). Not OHIP-covered. Requires MRI compatibility.

Reversible, oral, fertility-restorable on discontinuation. Specifically reduces uterine volume and bleeding without the irreversible step of surgery. Your gynecologist appears unfamiliar with this drug class — relugolix is FDA-approved for endometriosis and the LIBERTY adenomyosis subgroup data is favorable.

Key outcome: 22.2% reduction in uterine volume vs 5.8% placebo (Catherino 2025, LIBERTY adenomyosis subgroup). Linzagolix received EMA marketing authorization Dec 20, 2024 for endometriosis with off-label adenomyosis applicability.

Tradeoffs: Hot flashes, possible bone density effects with longer use. Combined with low-dose add-back hormone therapy in protocols. Not yet OHIP-covered for off-label adenomyosis use — would need private prescription.

Long-acting, removable on demand, fertility-restorable on removal. The 2024 Akhigbe meta-analysis found 29.5% complete dysmenorrhea remission with LNG-IUS (vs 73% with dienogest, but with 49% dienogest discontinuation rate — making LNG-IUS often the more durable real-world choice). Your gyn mentioned 'hormonal contraceptives' generally — Mirena specifically should be on the menu.

Key outcome: 29.5% complete dysmenorrhea remission. Better real-world tolerability than oral options. Protective endometrial effect for fertility timeline.

Tradeoffs: Requires placement procedure. Spotting common in first 3–6 months. Some users report mood/libido effects.

Higher symptom remission rate than LNG-IUS in head-to-head data, but with caveats. Worth a structured trial before considering surgery. Your gynecologist's mention of 'hormonal contraceptives' likely means combined OCPs — dienogest is a different class (progestin-only with anti-androgenic profile) with better adenomyosis-specific evidence.

Key outcome: 73% complete dysmenorrhea remission (Akhigbe 2024 meta), VAS pain reduction averaging −6 (Lin 2025 in-depth meta).

Tradeoffs: 49% of patients discontinued by 12 months due to side effects (irregular bleeding, mood, headache) per the head-to-head data. Not currently first-line in Ontario but available.

Minimally invasive, transcervical or laparoscopic. Better suited to focal adenomyosis than diffuse — MRI staging would clarify if you're a candidate. Active ADENOTREAT trial (NCT07195305) is comparing RFA vs UAE in France.

Key outcome: ~63% pain reduction at 12 months. Pregnancy rates 36–50% in available series. Less data than HIFU but improving.

Tradeoffs: Requires anaesthesia. Limited availability in Canada outside major academic centres. Long-term fertility data still maturing.

Heavy bleeding for 3+ days each cycle puts you at chronic risk of iron-deficiency anaemia, which compounds the fatigue you already report. Your Hgb of 131 is currently in range but cycles erode it. Restoring iron stores improves energy, mood, and exercise tolerance.

Caution — Get baseline ferritin, transferrin saturation, and CBC before supplementing. Iron overload is real if you over-supplement.

Magnesium has Cochrane-reviewed evidence for dysmenorrhea (modest effect size). Specifically helpful for the 'cramping' quality of pain your case describes. Glycinate form is well-tolerated and doesn't cause GI upset like other forms.

Caution — Check with doctor if on blood pressure medications or have kidney issues.

Adenomyosis involves chronic local inflammation. Mediterranean-style and lower-FODMAP patterns reduce systemic inflammation markers and may modestly reduce pain intensity. Several patient communities report meaningful improvement after 8-12 weeks of consistent change.

TENS has Cochrane-reviewed evidence for primary and secondary dysmenorrhea. Non-pharmacological, no side effects, can stack with naproxen. The ELECTRE trial (NCT07393295) is currently studying its specific application in adenomyosis.

Chronic pelvic pain often produces secondary pelvic floor muscle dysfunction (hypertonicity), which then worsens dyspareunia and cycle pain. A pelvic floor physiotherapist can release this tension and teach down-training exercises. Particularly relevant if you've noticed pain with intercourse worsening.

Energy demands of adenomyosis aren't constant — luteal phase and menses are physiologically more taxing. Working with the cycle (rather than against it) reduces flare severity. Particularly important given your cycles prevent you from working at peak.

Eleven years of being dismissed by doctors compounds psychological burden. Validated frustration, grief about fertility uncertainty, and anticipatory anxiety about the next dismissive appointment are clinically significant. Peer communities (Adenomyosis Fighters on Facebook, AAA's HealthUnlocked) reduce isolation; professional therapy with a chronic-illness-aware therapist addresses the deeper layer.