Background: Dysmenorrhea and menorrhagia are common consequences of adenomyosis. While conservative surgery can effectively preserve fertility in women with adenomyosis, they are still vulnerable to postoperative recurrence, for which a reliable long-term predictive tool is lacking. This study aimed to develop and validate a 5-year recurrence predictive model for adenomyosis patients after conservative surgery based on their clinical and imaging features.

Methods: In this retrospective study, 150 women aged 18–50 years who underwent uterus-preserving surgery for adenomyosis were analyzed. Clinical data, including imaging parameters, surgical characteristics, and postoperative management, were collected. Recurrence was defined as either a ≥3-point increase in Visual Analog Scale score for dysmenorrhea or a ≥50% increase in Pictorial Blood Assessment Chart score within five years. Multivariate Cox regression was used to construct a nomogram, with its predictive performance evaluated using concordance index (C-index), time-dependent receiver operating characteristic curves, calibration, and decision curve analysis (DCA).

Results: Four independent predictors were identified: older age, larger uterine volume, shorter duration of postoperative hormonal therapy, and concomitant endometriosis. The nomogram demonstrated good discriminative ability (C-index 0.766; AUCs 0.68, 0.73, 0.76 at 15, 24, and 48 months, respectively), along with reliable calibration and evident clinical net benefit. Kaplan–Meier analysis revealed that the nomogram effectively distinguished risk groups, with five-year recurrence-free survival rates of 78% in the low-risk group and 17% in the high-risk group.

Conclusion: By integrating clinical and imaging variables, the nomogram developed in this study demonstrates strong clinical applicability, accurately predicting recurrence risk in adenomyosis patients after conservative surgery and guiding personalized postoperative management.