A 32-year-old woman from Mumbai presents with secondary infertility of 2 years duration. She reports severe dysmenorrhea since her last delivery 4 years ago, which has progressively worsened. She also complains of chronic pelvic pain and deep dyspareunia. Her menstrual cycles are regular (28–30 days) but heavy. On examination, the uterus is fixed, retroverted, and tender. Transvaginal ultrasound shows multiple hypoechoic lesions in the myometrium with heterogeneous echotexture. What is the most likely diagnosis?

Explanation

## Diagnosis: Adenomyosis ### Clinical Presentation This patient presents with the classic triad of adenomyosis: | Feature | Mechanism | |---------|----------| | **Severe dysmenorrhea** | Increased prostaglandin production; myometrial contractions | | **Menorrhagia** | Abnormal angiogenesis; impaired hemostasis | | **Secondary infertility** | Impaired endometrial receptivity; abnormal myometrial contractility | ### Key Diagnostic Findings **Key Point:** Adenomyosis is defined as ectopic endometrial glands and stroma within the myometrium (>2.5 mm from the endometrial–myometrial junction). **High-Yield:** The **junctional zone** is the key imaging finding: - Transvaginal ultrasound: Heterogeneous, hypoechoic lesions in myometrium - MRI: Thickened junctional zone (>12 mm) with poor definition of endometrial–myometrial interface - This patient's imaging fits adenomyosis perfectly ### Pathophysiology ```mermaid flowchart TD A[Invagination of basalis endometrium into myometrium]:::outcome --> B[Increased prostaglandins & cytokines]:::outcome B --> C[Myometrial hypercontractility]:::outcome C --> D[Dysmenorrhea & Menorrhagia]:::outcome A --> E[Impaired endometrial receptivity]:::outcome E --> F[Reduced implantation rates]:::outcome F --> G[Secondary Infertility]:::urgent B --> H[Increased angiogenesis & neuroangiogenesis]:::outcome ``` ### Distinguishing Features: Adenomyosis vs. Endometriosis | Feature | Adenomyosis | Endometriosis | |---------|-------------|---------------| | **Location** | Within myometrium | Outside uterus (peritoneum, ovaries, bowel) | | **Age** | Typically ≥35 years; post-partum | Younger women (20–40 years) | | **Dysmenorrhea** | Severe, progressive | Variable; may improve with menses | | **Imaging** | Junctional zone thickening; heterogeneous myometrium | Ovarian cysts (chocolate cysts), peritoneal nodules | | **Infertility** | Secondary (post-partum) | Primary or secondary | | **Uterine size** | Enlarged, boggy, tender | Normal or slightly enlarged | **Clinical Pearl:** Adenomyosis is often a **diagnosis of exclusion** on imaging; definitive diagnosis requires histology. However, imaging findings in this case (heterogeneous myometrial lesions + junctional zone abnormality) are highly suggestive. ### Management 1. **Medical:** NSAIDs, combined oral contraceptives, progestin-only methods (levonorgestrel IUD, medroxyprogesterone) 2. **Surgical:** Hysterectomy (definitive treatment, but patient desires fertility) 3. **Fertility:** Assisted reproductive technology (ART) may improve outcomes; uterine artery embolization or adenomyosis ablation under investigation **Warning:** Adenomyosis significantly reduces implantation rates and increases miscarriage risk, even with ART. Prognosis for spontaneous conception is poor. [cite:DC Dutta's Textbook of Obstetrics 8e Ch 12; RCOG Green-top Guideline on Adenomyosis]