A 48-year-old woman comes to the office due to painful, heavy menses for the past 6 months. The patient has 4-5 days of heavy bleeding, often soaking through a tampon or sanitary napkin every few hours. Menstrual periods occur every 28-30 days. The patient is not on contraception and has no significant medical history. Vital signs are normal. Urine pregnancy test is negative. After an appropriate workup, a hysterectomy is performed, and the surgical specimen is shown below: Which of the following is the most likely diagnosis?

Question

A 48-year-old woman comes to the office due to painful, heavy menses for the past 6 months.  The patient has 4-5 days of heavy bleeding, often soaking through a tampon or sanitary napkin every few hours.  Menstrual periods occur every 28-30 days.  The patient is not on contraception and has no significant medical history.  Vital signs are normal.  Urine pregnancy test is negative.  After an appropriate workup, a hysterectomy is performed, and the surgical specimen is shown below:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3572_0a20_9249_7f429bfc51be_MD0001_00 This patient with heavy menses and dysmenorrhea has adenomyosis, the abnormal presence of endometrial glands and stroma within the uterine myometrium (ie, uterine wall). Adenomyosis typically occurs in women age >40, and risk factors include multiparity and prior uterine surgery (eg, cesarean delivery). The pathology of adenomyosis correlates with its clinical symptoms. Adenomyosis has a gross appearance as areas of dark red endometrial tissue within the myometrium. With each menstrual cycle, the endometrial tissue proliferates and sheds but the bleeding is confined within the uterine wall, causing dysmenorrhea. In addition, the ectopic endometrial glands induce myometrial hyperplasia and hypertrophy, creating a globular, uniformly enlarged uterus. This uterine enlargement also increases the surface area of the endometrial cavity, resulting in regular, heavy menses (eg, every 28-30 days). Definitive treatment is with hysterectomy. (Choice B) Chronic endometritis is an intrauterine polymicrobial infection that typically causes constant pelvic pain with irregular bleeding rather than dysmenorrhea and regular, heavy menses. Because the disease process is intracavitary, there is no associated uterine enlargement. Gross pathology may reveal intrauterine adhesions due to chronic intrauterine inflammation. (Choice C) A complete hydatidiform mole typically causes amenorrhea or irregular, first-trimester bleeding rather than regular, heavy menses. In addition, patients typically have markedly elevated β-hCG levels (ie, >100,000 mIU/mL). Gross pathology may reveal uterine enlargement, but there are typically numerous edematous intrauterine chorionic villi. (Choice D) Endometriosis is a common cause of dysmenorrhea due to ectopic implantation of endometrial glands and stroma in the abdominopelvic cavity; because the ectopic implants are extrauterine, patients do not have uterine enlargement or heavy menses. Gross pathology typically reveals black powder-burn lesions or ovarian cysts (ie, endometrioma). (Choice E) Uterine leiomyomas are benign, uterine smooth muscle cell tumors that can cause regular, heavy menses. However, gross pathology typically reveals an irregularly enlarged uterus with discrete tumors rather than a uniformly globular uterus. (Choice F) Uterine sarcomas are malignant uterine tumors. Affected patients typically have irregular, postmenopausal bleeding rather than regular, heavy menses. Gross pathology typically reveals a discrete uterine mass. Educational objective: Adenomyosis typically presents with regular (ie, cyclic), heavy, painful menses. Gross pathology reveals a uniformly enlarged, globular uterus with the abnormal presence of endometrial glands and stroma in the myometrium. __________ References: Adenomyosis: what is new? (http://www.ncbi.nlm.nih.gov/pubmed/26315369)

A 48-Year-Old Woman Comes to the Office Due to Painful