A 35-year-old woman from Mumbai presents with severe dysmenorrhea and progressively heavier menstrual bleeding over the past 3 years. She reports no intermenstrual bleeding or postcoital bleeding. Pelvic examination reveals a tender, boggy, uniformly enlarged uterus (approximately 12-week size). Transvaginal ultrasound shows a diffusely heterogeneous myometrium with poor definition of the junctional zone and increased vascularity on Doppler imaging. Endometrial thickness is 8 mm. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Adenomyosis ### Defining Features **Key Point:** Adenomyosis is characterized by the clinical triad of dysmenorrhea, menorrhagia, and a uniformly enlarged, tender, boggy uterus—all present in this patient. ### Pathophysiology Adenomyosis results from invagination of basalis endometrium into the myometrium, leading to: 1. **Myometrial hyperplasia and hypertrophy** → uterine enlargement 2. **Increased prostaglandin production** → dysmenorrhea and abnormal myometrial contractions 3. **Abnormal angiogenesis and increased vascularity** → menorrhagia 4. **Disrupted junctional zone** → loss of endometrial-myometrial interface ### Diagnostic Criteria: Adenomyosis vs. Fibroids | Feature | Adenomyosis | Fibroids | Adenomyosis + Fibroids | |---------|-------------|----------|------------------------| | **Dysmenorrhea** | Severe, progressive | Mild or absent | Severe | | **Uterine enlargement** | Uniform, tender, boggy | Irregular, firm, nodular | Irregular + boggy | | **Ultrasound appearance** | Diffuse heterogeneity, ill-defined junctional zone | Discrete hypoechoic lesions | Both features present | | **Vascularity (Doppler)** | Increased in junctional zone | Peripheral | Both zones | | **Size** | Rarely >14-week size | Can be large | Variable | | **Endometrial thickness** | Often normal or mildly increased | Normal | Variable | ### Ultrasound Findings in This Case **High-Yield:** The **loss of junctional zone definition** and **diffuse myometrial heterogeneity** on transvaginal ultrasound are hallmark features of adenomyosis. The increased vascularity on Doppler reflects abnormal neovascularization within adenomyotic foci. ### Clinical Pearl **Clinical Pearl:** Adenomyosis is often a diagnosis of exclusion in reproductive-age women with dysmenorrhea and menorrhagia when structural lesions (fibroids, polyps) have been ruled out. MRI is the gold standard for diagnosis when ultrasound is inconclusive, showing junctional zone thickening (>12 mm) and myometrial cysts. ### Management Algorithm ```mermaid flowchart TD A[Adenomyosis with Heavy Bleeding & Dysmenorrhea]:::outcome --> B{Desire fertility?}:::decision B -->|Yes| C[First-line: NSAIDs + Levonorgestrel IUS or COCs]:::action B -->|No| D[First-line: Levonorgestrel IUS or COCs]:::action C --> E{Adequate response?}:::decision D --> E E -->|Yes| F[Continue medical management]:::action E -->|No| G[Consider GnRH agonists or hysterectomy]:::action ``` ### Mnemonic for Adenomyosis Presentation **Mnemonic: "ADENOMYOSIS"** - **A**bnormal uterine bleeding (menorrhagia) - **D**ysmenorrhea (severe, progressive) - **E**nlarged uterus (uniform, tender, boggy) - **N**ormal endometrium (or mildly thickened) - **O**bstructed junctional zone (on ultrasound) - **M**yometrial heterogeneity (diffuse) - **Y**oung to middle-aged women (reproductive years) - **O**ften multiparous - **S**evere pain with bleeding - **I**nfertility (if desired) - **S**econdary dysmenorrhea [cite:Ferenczy & Bergeron, Adenomyosis: Pathophysiology and Clinical Impact; FIGO Classification]