Updated: 11/29/2021

Adenomyosis

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  • 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
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(M2.GN.17.4774) A 42-year-old G3P3003 presents to her gynecologist for an annual visit. She complains of urinary incontinence when jogging since the birth of her last child three years ago. Her periods are regular every 30 days. The patient also has cramping that is worse before and during her period but always present at baseline. She describes a feeling of heaviness in her pelvis that is exacerbated by standing for several hours at her job as a cashier. The patient has had two spontaneous vaginal deliveries, one caesarean section, and currently uses condoms for contraception. She is obese and smokes a pack of cigarettes a day. Her mother died of breast cancer at age 69, and her aunt is undergoing treatment for endometrial cancer. The patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 142/81 mmHg, and respirations are 13/min. Pelvic exam is notable for a uterine fundus palpated just above the pubic symphysis and a boggy, smooth texture to the uterus. There is no tenderness or mass in the adnexa, and no uterosacral nodularity is noted. Which of the following is a classic pathological feature of this patient’s most likely diagnosis?

QID: 109118

Presence of endometrial tissue outside of the uterus

0%

(0/16)

Presence of endometrial tissue within the myometrium

62%

(10/16)

Focal hyperplasia of the myometrium

6%

(1/16)

Nuclear atypia of endometrial cells

19%

(3/16)

No pathognomonic findings expected

12%

(2/16)

M 6 D

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(M2.GN.17.4766) A 44-year-old G2P2 African American woman presents to her gynecologist for dysmenorrhea. She reports that for the past few months, she has been having severe pain during her menses. She also endorses menstrual bleeding that has been heavier than usual. The patient reports that her cycles are regular and occur every 30 days, and she denies both dyspareunia and spotting between her periods. Her last menstrual period was two weeks ago. In terms of her obstetric history, the patient had two uncomplicated pregnancies, and she had no difficulty becoming pregnant. She has never had an abnormal pap smear. Her past medical history is otherwise significant for hyperlipidemia and asthma. On physical exam, the patient’s uterus is tender, soft, and enlarged to the size of a pregnant uterus at 10 weeks of gestation. She is non-tender during vaginal exam, without cervical motion tenderness or adnexal masses. Her BMI is 24 kg/m2. A urine pregnancy test is negative.

Which of the following is the most likely diagnosis for this patient?

QID: 109083

Hyperplastic overgrowths of endometrial glands and stroma

13%

(4/30)

Malignant invasion of endometrial cells into uterine myometrium

3%

(1/30)

Presence of endometrial glands and stroma in uterine myometrium

70%

(21/30)

Presence of endometrial glands and stroma outside the uterus

0%

(0/30)

Benign smooth muscle tumor of the uterus

13%

(4/30)

M 6 D

Select Answer to see Preferred Response

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