Snapshot A 43-year-old woman who is Gravida 3, Para 2 and Aborta 1, presents with increasing, worsening pain with menses, along with progressively heavier menstrual bleeding. Pelvic examination reveals a diffusely enlarged, tender, and boggy uterus. Serum β-hCG is negative. Transvaginal sonogram showed an enlarged uterus with a thickened posterior myometrium (arrows). Summary Invasion of endometrial glands into uterine myometrium EPIDEMIOLOGY women ages 35-50 Etiology Pathogenesis largely unknown Associated conditions often coexists with other uterine diseases leiomyomas endometriosis Presentation Symptoms dysmenorrhea menorrhagia chronic pelvic pain Physical exam uterus is uniformly smooth large soft globular boggy tender Imaging Sonogram sensitivity of 72% and specificity of 81% MRI (T2-weighted) sensitivity of 77% and specificity of 89% best used when trying to exclude malignant neoplasia both modalities show diffusely enlarged uterus with some cystic areas within myometrium Studies Initial test to order in patient with enlarged uterus β-hCG Differential Diagnosis Leiomyoma Pregnancy Endometrial polyp Diagnosis Diagnosis is based on clinical history and exam Definitive diagnosis hysterectomy and histology Treatment Symptomatic treatment for dysmenorrhea levonorgestrel-releasing intrauterine contraception aromatase inhibitors When fertility is no longer needed or failure of medical therapy hysterectomy Complications Controversial evidence linking adenomyosis with infertility