A 32-year-old woman presents with severe dysmenorrhea and chronic pelvic pain that has progressively worsened over the past 3 years. She reports that pain begins 1–2 days before menses and persists throughout menstruation. On examination, the uterus is tender, boggy, and uniformly enlarged to about 12 weeks size. Transvaginal ultrasound shows a heterogeneous myometrium with indistinct junctional zones and no discrete nodules or cysts. Her hemoglobin is 9.2 g/dL. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Adenomyosis ### Key Clinical Features **Key Point:** Adenomyosis is characterized by the presence of endometrial glands and stroma within the myometrium, causing a diffusely enlarged, tender, boggy uterus. The clinical presentation in this case is classic for adenomyosis: - **Dysmenorrhea**: Progressive, severe pain during menses (not before, as in endometriosis) - **Chronic pelvic pain**: Year-round discomfort due to myometrial inflammation - **Uterine enlargement**: Diffuse, uniform enlargement (typically ≤12 weeks size) - **Tender, boggy uterus**: Characteristic feel on bimanual examination - **Secondary infertility/anemia**: Common sequelae ### Imaging Findings | Feature | Adenomyosis | Endometriosis | Fibroids | |---------|-------------|---------------|----------| | **Uterine size** | Diffusely enlarged, uniform | Normal or minimally enlarged | Irregular, nodular | | **Junctional zone** | Indistinct, thickened (>12 mm) | Normal | Normal | | **Myometrial pattern** | Heterogeneous, striated | Normal | Well-defined masses | | **Imaging modality** | TVS, MRI best | TVS, laparoscopy | TVS, MRI | **High-Yield:** Transvaginal ultrasound (TVS) and MRI are the gold standards for adenomyosis diagnosis. The **indistinct junctional zone** and **heterogeneous myometrium** are pathognomonic findings. ### Pathophysiology 1. Invagination of basalis endometrium into myometrium 2. Disruption of junctional zone architecture 3. Myometrial hypercontractility and inflammation 4. Increased prostaglandin production → dysmenorrhea and pelvic pain **Clinical Pearl:** Unlike endometriosis (which causes pain *before* menses due to peritoneal irritation), adenomyosis causes pain *during* menses due to myometrial contractions against ectopic endometrial tissue. ### Management Approach ```mermaid flowchart TD A[Adenomyosis diagnosed]:::outcome --> B{Fertility desired?}:::decision B -->|No| C[NSAIDs + hormonal therapy]:::action C --> D[COCs, progestins, or levonorgestrel IUD]:::action B -->|Yes| E[Assisted reproduction]:::action E --> F[IVF/ICSI preferred over surgery]:::action C --> G{Refractory to medical therapy?}:::decision G -->|Yes| H[Hysterectomy definitive cure]:::action ``` **Key Point:** Medical management is first-line. NSAIDs reduce prostaglandins; hormonal contraceptives suppress endometrial growth. Hysterectomy is the only definitive cure but is reserved for women who have completed childbearing. [cite:Jeffcoate's Principles of Gynaecology Ch 24]