A 42-year-old woman from Delhi presents with menorrhagia for the past 8 months. She reports soaking 8–10 pads per day during menses, with passage of clots. Her cycles are regular (28 days) but prolonged (7–8 days). On examination, the uterus is uniformly enlarged, firm, and mobile. Pelvic ultrasound shows a heterogeneous uterus with multiple hypoechoic lesions within the myometrium. Hemoglobin is 9.2 g/dL. What is the most likely diagnosis?

## Diagnosis: Adenomyosis ### Clinical Presentation **Key Point:** The classic triad of adenomyosis is menorrhagia, dysmenorrhea, and a uniformly enlarged, "boggy" or firm uterus in a woman of reproductive age (typically 40–50 years). Regular cycles with heavy, prolonged bleeding and clot passage are characteristic. ### Ultrasound Findings **High-Yield:** The hallmark ultrasound findings of adenomyosis include: - **Heterogeneous myometrium** with diffuse echotexture changes - **Multiple hypoechoic lesions within the myometrium** (representing ectopic endometrial glands and surrounding smooth muscle hypertrophy) - **Diffusely enlarged uterus** without discrete, well-defined masses - Asymmetric myometrial thickening and myometrial cysts These findings are **distinct from leiomyomas**, which appear as **discrete, well-defined hypoechoic masses** with a pseudocapsule, often causing irregular uterine contour rather than uniform enlargement. ### Pathophysiology of Menorrhagia in Adenomyosis 1. Ectopic endometrial glands within the myometrium respond to hormonal stimulation → increased bleeding 2. Disruption of normal myometrial architecture → impaired uterine contractility → prolonged, heavy bleeding 3. Increased endometrial surface area and abnormal prostaglandin production 4. Junctional zone disruption → abnormal angiogenesis ### Key Distinguishing Features | Feature | Adenomyosis | Leiomyomas | DUB | Endometrial Cancer | |---------|------------|-----------|-----|-------------------| | **Uterine size** | Uniformly enlarged, firm/boggy | Irregular enlargement, discrete masses | Normal | Normal or slightly enlarged | | **Ultrasound** | Heterogeneous myometrium, diffuse hypoechoic areas, NO discrete masses | Discrete well-defined hypoechoic masses with pseudocapsule | Normal | Endometrial thickening, mass | | **Cycle regularity** | Regular | Regular | Irregular | Irregular | | **Age** | 40–50 years | 30–50 years | Reproductive age | >50 years | | **Dysmenorrhea** | Common | Less common | Absent | Absent | **Clinical Pearl (Williams Gynecology / Dutta's Gynecology):** Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium, at least 2.5 mm below the basal endometrium. It classically presents in multiparous women aged 40–50 with menorrhagia and a uniformly enlarged, firm uterus. Ultrasound showing a **heterogeneous myometrium with diffuse hypoechoic lesions** (not discrete masses) is the key differentiator from fibroids. ### Why Not Leiomyomas? - Fibroids produce **discrete, well-defined hypoechoic masses** on ultrasound, often with irregular uterine contour - The stem describes a **uniformly enlarged** uterus with **diffuse myometrial heterogeneity** — this pattern is characteristic of adenomyosis, not fibroids - Fibroids typically cause an **irregular, lobulated** uterine contour rather than uniform enlargement ### Secondary Effects - Iron deficiency anemia (Hb 9.2 g/dL) from chronic blood loss - Definitive diagnosis: MRI (sensitivity ~78%, specificity ~88%) or histopathology after hysterectomy **Tip:** On NEET PG/INI-CET, when the stem describes a uniformly enlarged uterus with heterogeneous myometrium and diffuse hypoechoic lesions (no discrete masses), the answer is **adenomyosis**. Discrete hypoechoic masses with pseudocapsule = fibroids.