A 38-year-old woman from Mumbai presents with a 6-month history of progressively heavy and prolonged menstrual bleeding (duration 8–10 days, soaking 10+ pads daily). Her cycles are irregular, occurring every 21–35 days. She has severe dysmenorrhea requiring high-dose NSAIDs and occasional work absence. On examination, the uterus is tender, boggy, and uniformly enlarged to 14 weeks size. Pelvic ultrasound shows a heterogeneous, thickened myometrium with indistinct endometrial–myometrial interface and no discrete masses. Hemoglobin is 8.5 g/dL. What is the most likely diagnosis?

Explanation

## Diagnosis: Adenomyosis ### Clinical Presentation **Key Point:** The combination of heavy, prolonged, irregular menstrual bleeding with severe dysmenorrhea, a uniformly enlarged tender boggy uterus, and a heterogeneous myometrium with indistinct endometrial–myometrial interface is pathognomonic for adenomyosis. ### Pathophysiology **High-Yield:** Adenomyosis results from invagination of basalis endometrium into the myometrium, causing: 1. Increased myometrial contractility and dysrhythmia → dysmenorrhea 2. Increased endometrial vascularity and impaired hemostasis → heavy bleeding 3. Diffuse myometrial inflammation → dysmenorrhea and bleeding ### Diagnostic Criteria | Feature | Adenomyosis | Fibroids | | --- | --- | --- | | **Uterine shape** | Uniformly enlarged, globular, tender | Irregular, bumpy, firm | | **Ultrasound findings** | Indistinct interface, heterogeneous myometrium, no masses | Discrete hypoechoic lesions, preserved interface | | **Bleeding pattern** | Heavy + prolonged + dysmenorrhea | Heavy ± clots, regular cycles | | **Myometrial thickness** | Diffusely thickened (>12 mm) | Normal or focal thickening | | **Age** | 40–50 years (can occur earlier) | 30–50 years | **Clinical Pearl:** The presence of a **boggy** (soft, spongy) uterus with dysmenorrhea is a red flag for adenomyosis; fibroids feel firm and irregular. ### Management Algorithm ```mermaid flowchart TD A[Adenomyosis diagnosed]:::outcome --> B{Fertility desired?}:::decision B -->|Yes| C[Medical management first]:::action B -->|No| D[Hysterectomy definitive]:::action C --> E[GnRH agonists, SPRMs, LNG-IUS]:::action E --> F{Response?}:::decision F -->|Good| G[Continue medical therapy]:::action F -->|Poor| H[Consider hysterectomy]:::action D --> I[Cure achieved]:::outcome ``` **High-Yield:** First-line medical management includes: - **LNG-IUS (Mirena)**: Most effective, reduces bleeding by 50–90% - **GnRH agonists**: Preoperative shrinkage or bridge therapy - **SPRMs (Ulipristal acetate)**: Newer option, effective for bleeding and pain - **NSAIDs + Tranexamic acid**: Symptomatic relief **Warning:** Hysterectomy is the only definitive cure; medical therapy is palliative in adenomyosis.