Review Question - QID 109118

This woman presents with pelvic pain worse during menstruation and a uniformly enlarged uterus on exam, most consistent with adenoymosis. This condition is characterized by the presence of endometrial tissue within the myometrium.

Invasion of the endometrium into the myometrium at least one low power field past the endomyometrial junction defines adenomyosis. The cause is unknown, although a history of uterine trauma (i.e., Caesarean section, dilation and evacuation, etc.) may be associated. Because of increased endometrial surface, there is often heavy menstrual bleeding. Swelling of the endometrial islands confined by myometrium causes pelvic pain.

Incorrect Answers:
Answer 1: Presence of endometrial tissue outside of the uterus is the definition of endometriosis, which may also present with painful menstruation. However, it typically does not cause the uterine enlargement or heavy bleeding seen in this patient.

Answer 3: Focal hyperplasia of the myometrium occurs in uterine leiomyomata, which could result in the heavy bleeding and cramping experienced by this patient. However, the pelvic exam classically reveals an irregularly contoured uterus, whereas this patient’s uterus is smooth.

Answer 4: Nuclear atypia of endometrial cells occurs in endometrial cancer, which should be on the differential for any abnormal uterine bleeding in an obese woman over 35 years of age. However, chronic pelvic pain would be a rare presentation of such malignancy and makes adenomyosis more likely.

Answer 5: No pathognomonic pathological findings are expected in some other causes of chronic pelvic pain, such as pelvic congestion syndrome. This patient does have the characteristic baseline pain that is worse with standing. However, heavy bleeding is uncommon with pelvic congestion.

Bullet Summary:
Adenomyosis is caused by endometrial expansion into the myometrium, often presents with pelvic pain, and a uniformly enlarged uterus.