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Summary Table

Category	Detail
Risk Factors	Multiparous women, age 40-50, prior uterine surgery (cesarean section, curettage, myomectomy), history of endometriosis
Etiology	Ectopic endometrial glands and stroma invading into the myometrium
Patient Presentation	Heavy menstrual bleeding (menorrhagia), progressive dysmenorrhea that worsens with age
Classic Physical Exam	Diffusely enlarged, boggy, globular, tender uterus
Key Diagnostic Results	Transvaginal ultrasound showing heterogeneous myometrium with poorly defined endometrial-myometrial junction; MRI showing thickened junctional zone >12 mm
Management	Definitive: hysterectomy. Medical: hormonal therapy (levonorgestrel IUD, GnRH agonists, combined oral contraceptives)
Keywords	"Boggy uterus," "uniformly enlarged uterus," "symmetrically enlarged," "painful heavy periods in a multiparous woman in her 40s"

1. Pathophysiology

Adenomyosis occurs when endometrial glands and stroma penetrate through the endometrial-myometrial interface (junctional zone) and embed within the myometrium. Unlike endometriosis, where endometrial tissue is found outside the uterus entirely, adenomyosis is confined within the uterine wall itself. This distinction is essential for exam reasoning.

The ectopic endometrial tissue within the myometrium responds to cyclic hormonal stimulation just as the normal endometrium does. During each menstrual cycle, these embedded islands of tissue undergo proliferation, secretion, and attempted shedding. Because the blood and sloughed tissue are trapped within the muscular wall, this triggers a local inflammatory response and reactive hypertrophy of the surrounding smooth muscle. Over time, this repeated cycle of hemorrhage, inflammation, and muscular hyperplasia causes the uterus to become diffusely and symmetrically enlarged.

The dysmenorrhea in adenomyosis is explained by prostaglandin release from the entrapped endometrial tissue and from the inflammatory infiltrate within the myometrium. The pain tends to be progressive, worsening over years, because the process is cumulative. The menorrhagia results from two mechanisms: first, the enlarged uterine cavity has a greater endometrial surface area, leading to heavier bleeding; second, the myometrial invasion disrupts normal contractile function of the uterus, impairing its ability to compress spiral arterioles and achieve hemostasis after menstruation.

An important concept for vignette interpretation: adenomyosis is an estrogen-dependent condition. This is why it is most symptomatic during reproductive years and tends to regress after menopause when estrogen levels decline.

2. Classification and Clinical Manifestation

Type	Description	Clinical Implication
Diffuse adenomyosis	Widespread distribution of ectopic endometrial tissue throughout the myometrium	More common form; causes the classic globally enlarged, boggy uterus; associated with more pronounced menorrhagia
Focal adenomyosis (adenomyoma)	Localized collection forming a discrete nodule within the myometrium	Can mimic a leiomyoma on imaging and exam; important differential on ultrasound

Clinical Manifestations

Feature	Detail
Menorrhagia	Present in roughly 50-60% of cases; heavy, prolonged menstrual bleeding
Dysmenorrhea	Progressive, crampy, midline pelvic pain that begins before menses and persists throughout; worsens over successive cycles
Chronic pelvic pain	Dull, constant discomfort outside of menses in advanced cases
Dyspareunia	Deep dyspareunia from uterine tenderness and enlargement
Uterine enlargement	Typically enlarged to the size of a 10-12 week gravid uterus, rarely exceeding this
Subfertility	Increasingly recognized association; disrupted junctional zone impairs implantation and sperm transport

A key clinical pearl: roughly one-third of patients with adenomyosis are asymptomatic, and the diagnosis is found incidentally on imaging or at the time of hysterectomy performed for other indications.

3. Diagnostic Workup

Test	Role	Key Findings
Transvaginal ultrasound (TVUS)	Best initial test	Heterogeneous myometrium, myometrial cysts, asymmetric myometrial thickening, poorly defined endometrial-myometrial border, "Venetian blind" shadowing
MRI pelvis	Most accurate non-invasive test	Junctional zone thickness >12 mm is diagnostic; high-signal foci on T2-weighted images representing ectopic endometrial glands
Histopathology of hysterectomy specimen	Gold standard / confirmatory test	Endometrial glands and stroma found >2.5 mm below the endometrial-myometrial junction

Transvaginal ultrasound is the first-line imaging study for any woman presenting with abnormal uterine bleeding and dysmenorrhea. In adenomyosis, the ultrasound typically reveals a globularly enlarged uterus with a heterogeneous, thickened myometrium. Small anechoic cysts (representing hemorrhagic foci) within the myometrium and linear striations extending from the endometrium into the myometrium are characteristic. The endometrial-myometrial border often appears indistinct. Ultrasound sensitivity for adenomyosis ranges from 65-80%, which is operator-dependent.

When ultrasound is inconclusive or when differentiation from leiomyoma is needed, pelvic MRI is the next step. MRI is superior in distinguishing adenomyosis from fibroids. The hallmark finding is a junctional zone exceeding 12 mm in thickness on T2-weighted sequences. The junctional zone normally appears as a low-signal band between the endometrium and outer myometrium; in adenomyosis, it is widened and contains punctate bright foci representing trapped glandular tissue. A junctional zone ratio (maximum to minimum thickness) >1.5 also supports the diagnosis when the absolute measurement is borderline.

The true gold standard remains histological examination of the uterine specimen after hysterectomy, confirming endometrial glands and stroma at a depth greater than 2.5 mm from the basal endometrium. This means that a definitive preoperative tissue diagnosis is not routinely obtained. For exam purposes, the test-writer will frame the best initial test as TVUS and the most accurate imaging test as MRI.

Importantly, endometrial biopsy does not diagnose adenomyosis. An endometrial biopsy samples only the superficial endometrium and cannot reach the myometrium where the pathology resides. This is a commonly tested concept and a frequent trap.

4. Management and Treatment

Setting	Treatment	Detail
Mild symptoms / fertility desired	NSAIDs	Ibuprofen 400-600 mg every 6-8 hours during menses for pain control
Medical first-line	Levonorgestrel-releasing IUD (LNG-IUD)	52 mg device, effective for up to 5 years; reduces menorrhagia and dysmenorrhea by inducing endometrial atrophy
Medical alternatives	Combined oral contraceptives	Continuous regimen preferred to suppress cycling; reduces bleeding and pain
	GnRH agonists (e.g., leuprolide 3.75 mg IM monthly)	Creates a hypoestrogenic state; highly effective but limited to 6 months due to bone density loss; often used as a bridge to surgery
	Oral progestins (norethindrone acetate 5 mg daily)	Useful when IUD is contraindicated or declined
	GnRH antagonists (elagolix)	Oral option for symptom control with dose-dependent estrogen suppression
Definitive treatment	Hysterectomy	Only curative option; indicated for completed childbearing with refractory symptoms
Fertility-sparing surgical option	Adenomyomectomy / excision	Considered in focal adenomyosis when fertility is desired; not widely standardized

The first step is to assess whether the patient desires future fertility, as this fundamentally determines the treatment pathway.

For a woman who wants symptom relief and has not completed childbearing, the levonorgestrel IUD is the preferred initial intervention. It delivers local progesterone directly to the endometrium, causing decidualization and atrophy of both the eutopic and ectopic endometrial tissue. Studies consistently show significant reduction in menstrual blood loss and improvement in dysmenorrhea. The advantage over systemic hormonal therapy is the minimal systemic side-effect profile.

If the LNG-IUD is not tolerated, contraindicated, or insufficient, combined oral contraceptives administered in a continuous fashion (skipping the placebo week) are a reasonable alternative. They suppress ovulation and reduce endometrial proliferation.

GnRH agonists such as leuprolide are reserved for more refractory cases or as a temporizing measure before surgery. By creating a medical menopause, they dramatically shrink the uterus and reduce symptoms. However, prolonged use beyond 6 months causes significant bone mineral density loss and vasomotor symptoms. Add-back therapy with low-dose estrogen-progestin (norethindrone acetate 5 mg daily) can extend use while mitigating bone loss.

For a woman who has completed childbearing and has failed medical management, the next best step is hysterectomy. This is the only definitive cure because adenomyotic tissue is diffusely embedded in the myometrium and cannot be fully excised while preserving the uterus. Ovarian conservation is standard unless there is a concurrent indication for oophorectomy.

Uterine artery embolization (UAE) and MRI-guided focused ultrasound ablation have been explored as alternatives. UAE can reduce symptoms in the short term, but long-term data for adenomyosis are less robust than for fibroids. These options may appear as answer choices but are not considered first-line.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Uterine leiomyoma (fibroid)	Also causes menorrhagia and uterine enlargement in reproductive-age women	Fibroids produce an irregularly enlarged uterus with discrete, firm, rubbery masses; adenomyosis produces a diffusely, symmetrically enlarged, boggy, tender uterus. On ultrasound, fibroids are well-circumscribed with a pseudocapsule; adenomyosis has no clear border. MRI distinguishes them definitively.
Endometriosis	Shares dysmenorrhea, dyspareunia, and is also estrogen-dependent	Endometriosis involves tissue outside the uterus (ovaries, cul-de-sac, peritoneum); uterine size is typically normal. Nodularity of the uterosacral ligaments and adnexal masses (endometriomas) point toward endometriosis. Both can coexist.
Endometrial polyp	Causes abnormal uterine bleeding	Polyps cause intermenstrual bleeding or postmenstrual spotting rather than heavy menstrual flow with dysmenorrhea. Ultrasound shows a discrete intracavitary lesion, not myometrial changes.
Endometrial carcinoma	Must be considered in any woman with abnormal uterine bleeding, particularly if >45 years old	Endometrial biopsy will show atypical/malignant cells. Adenomyosis has normal endometrial histology on biopsy. The vignette for carcinoma typically includes postmenopausal bleeding or risk factors such as obesity, diabetes, unopposed estrogen.
Chronic endometritis	Causes pelvic pain and abnormal bleeding	Endometritis presents with intermenstrual bleeding, purulent discharge, and uterine tenderness that is not cyclic. Endometrial biopsy showing plasma cells confirms the diagnosis.

6. Traps and High-Yield Pearls

The most common way students lose points on adenomyosis questions is by confusing it with uterine fibroids. Both conditions occur in a similar demographic and both cause heavy bleeding and an enlarged uterus. The vignette will differentiate them through the description of the uterus on bimanual exam: a globally enlarged, soft, boggy, symmetrically tender uterus points to adenomyosis, while a uterus with irregular contour, discrete firm nodules, or asymmetric enlargement points to fibroids. If a question describes a "bulky uterus" in a multiparous 40-year-old woman with worsening dysmenorrhea, adenomyosis should be the leading consideration.

A second trap involves the diagnostic workup. Students sometimes select endometrial biopsy as the test to confirm adenomyosis. Remember: endometrial biopsy cannot diagnose adenomyosis because the disease lives within the myometrium, below the sampling depth of a biopsy curette. Endometrial biopsy is performed in this clinical scenario to exclude endometrial hyperplasia or carcinoma, not to confirm adenomyosis. The best initial imaging test is transvaginal ultrasound; the most accurate imaging test is MRI.

A third pearl: adenomyosis and endometriosis frequently coexist. If a vignette describes a patient with features of both (cyclic heavy painful menses with a boggy uterus AND endometriomas on imaging), do not assume one diagnosis excludes the other. However, when the question stem asks you to identify the cause of the uterine enlargement, focus on adenomyosis.

Finally, for management sequencing: the test-writer expects you to recognize the LNG-IUD as the first-line medical therapy and hysterectomy as the definitive treatment. GnRH agonists are a bridge, not a long-term solution. If the vignette describes a patient who has completed childbearing and failed medical therapy, hysterectomy is the next best step.

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