A 38-year-old woman from Mumbai presents with 8 months of progressively heavy and prolonged menstrual bleeding. Her cycles remain regular (30 days), but flow now lasts 9 days with passage of large clots. She reports severe cramping pain during menses (dysmenorrhea) and deep pelvic pain during intercourse (dyspareunia). On examination, the uterus is uniformly enlarged, boggy, and tender. Pelvic ultrasound shows diffuse heterogeneous thickening of the myometrium with indistinct junctional zones and normal endometrial thickness (3 mm). Hemoglobin is 8.8 g/dL. What is the most likely diagnosis?

Explanation

## Diagnosis: Adenomyosis ### Clinical Presentation **Key Point:** The triad of heavy menstrual bleeding + dysmenorrhea + dyspareunia in a 38-year-old woman with a uniformly boggy enlarged uterus is pathognomonic for adenomyosis. ### Pathophysiology **High-Yield:** Adenomyosis results from invagination of basalis endometrium into the myometrium, creating: 1. Ectopic endometrial glands and stroma within muscle 2. Increased myometrial vascularity and angiogenesis 3. Impaired myometrial contractility 4. Elevated local prostaglandins (PGE~2~, PGF~2~α) → dysmenorrhea 5. Defective endometrial–myometrial interface (junctional zone disruption) ### Ultrasound Findings **Clinical Pearl:** The hallmark ultrasound sign is **loss of the normal junctional zone** — the interface between endometrium and myometrium becomes indistinct and heterogeneous. This reflects the invasion of endometrial tissue into muscle. Normal junctional zone thickness is <12 mm; in adenomyosis it is >12 mm or ill-defined. ### Diagnostic Criteria | Feature | Adenomyosis | Leiomyoma | Endometrial Hyperplasia | | --- | --- | --- | --- | | **Uterine consistency** | Boggy, tender | Firm, nontender | Normal | | **Bleeding pattern** | Heavy, dysmenorrheic | Heavy, regular, painless | Irregular, prolonged | | **Dyspareunia** | Present (deep) | Absent | Absent | | **Ultrasound** | Diffuse heterogeneous myometrium, blurred JZ | Discrete heterogeneous mass | Normal or thickened endometrium | | **Age group** | 40–50 years (can be 30s) | Reproductive/perimenopausal | Perimenopausal/postmenopausal | | **Parity** | Multiparous (curettage history) | Any | Nulliparous, obese | ### Why Not Leiomyoma? **Warning:** Although both cause heavy bleeding, leiomyomas present with a **firm, nontender uterus** and a **discrete heterogeneous intramural mass** on ultrasound. This patient has a **diffuse, boggy myometrium** with **blurred junctional zones** — adenomyosis, not fibroid. ### Mechanism of Dysmenorrhea **Mnemonic: PAIN in Adenomyosis** — **P**rostaglandins elevated, **A**denomyotic invasion, **I**ncreased vascularity, **N**euronal sensitization. Elevated prostaglandins cause: - Increased myometrial contractions (dysmenorrhea) - Vasoconstriction → ischemia → pain - Increased sensitivity to pain (neurogenic inflammation) ### Management Implications **Key Point:** First-line treatment is NSAIDs (for dysmenorrhea) + levonorgestrel IUS (Mirena) or combined oral contraceptives. Hysterectomy is definitive but reserved for women who have completed childbearing. [cite:Jeffcoate's Principles of Gynaecology Ch 19]