Endometriosis and Adenomyosis

A 32-year-old Indian woman presents with severe dysmenorrhea and chronic pelvic pain for the past 3 years. She reports that pain begins 1–2 days before menstruation and persists throughout her cycle, worsening during menses. On examination, the uterus is uniformly enlarged, tender, and boggy. Transvaginal ultrasound shows a heterogeneous myometrium with ill-defined junctional zones and small cystic spaces within the myometrium. Her serum CA-125 is mildly elevated at 42 U/mL. What is the most likely diagnosis?

A 38-year-old woman with adenomyosis and severe menorrhagia (menstrual blood loss >80 mL/cycle) has failed to respond to NSAIDs and combined oral contraceptives over 6 months. She is not a candidate for surgery. What is the drug of choice for medical management?

A 32-year-old woman presents with severe dysmenorrhea and chronic pelvic pain for 3 years. Pelvic examination reveals a fixed, retroverted uterus with nodularity in the uterosacral ligaments. Transvaginal ultrasound shows multiple small cystic lesions in the myometrium. What is the most specific investigation to confirm the diagnosis of adenomyosis?

A 28-year-old nulliparous woman presents with a 4-year history of severe cyclic pelvic pain, dyspareunia, and infertility. She reports that pain starts 3–4 days before her period and improves after menses ends. On examination, there are tender nodules palpable in the pouch of Douglas. Transvaginal ultrasound reveals multiple small cysts in both ovaries (largest 2 cm) with normal myometrial echotexture and a normal junctional zone. Diagnostic laparoscopy shows chocolate cysts on the ovaries and peritoneal implants. What is the most likely diagnosis?

A 32-year-old woman presents with severe dysmenorrhea and chronic pelvic pain for 3 years. Transvaginal ultrasound shows heterogeneous echotexture of the myometrium with ill-defined junctional zone and small cystic spaces. She has no infertility concerns and wishes to retain her uterus. What is the most appropriate next step in management?