A 46-year-old woman, gravida 2 para 2, comes to the office due to increasingly heavy menses. The patient's menstrual periods previously occurred every 30 days and consisted of 4-5 days of moderate bleeding with mild cramping. However, over the past 6 months, her menses have consisted of 5-6 days of heavy bleeding with the passage of clots and severe abdominal cramping. The cramping has been unresponsive to consistent ibuprofen administration. The patient reports increasing fatigue and often sleeps 9-10 hours a night. She had 2 vaginal deliveries and a tubal ligation after the birth of her second child. The patient has no known chronic medical conditions. In addition to ibuprofen, she takes a daily multivitamin. The patient is an accountant and is unable to work during her menstrual cycle due to the pain. She drinks a glass of wine with dinner most days of the week but does not use tobacco or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 105/min. BMI is 22 kg/m². The thyroid is nontender with no obvious enlargement or masses. Pelvic examination reveals a uniformly enlarged, mobile uterus. No rectovaginal or adnexal tenderness is present. On speculum examination, the vagina appears well rugated and the cervix has no visible lesions. Which of the following is the most likely diagnosis in this patient?

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Explanation: 11ec2b69_beed_0f88_8f63_5b1b9998099e_MD0005_00 Adenomyosis is the abnormal presence of endometrial glands and stroma within the uterine myometrium. This ectopic endometrial tissue induces myometrial hyperplasia and hypertrophy, resulting in a uniformly enlarged uterus (eg, globular uterus). Adenomyosis is characterized by dysmenorrhea (due to endometrial proliferation in the myometrium) and regular, heavy menses (due to increased surface area of the endometrium). Patients can also have symptomatic anemia (eg, fatigue, tachycardia) secondary to chronic heavy menstrual bleeding. Risk factors for adenomyosis include age >40, multiparity, and prior uterine surgery (eg, cesarean delivery, myomectomy). Adenomyosis Although adenomyosis is definitively diagnosed via pathology, a presumptive diagnosis can be made clinically. Imaging with either pelvic ultrasound or MRI may help distinguish adenomyosis from malignancy, leiomyomas, or endometriosis. Medical management with progestins (eg, progestin intrauterine device, medroxyprogesterone acetate) is provided to patients who have not completed childbearing. However, adenomyosis typically does not completely respond to medical therapy; definitive treatment is via hysterectomy. (Choice B) Endometriosis can present with dysmenorrhea and heavy menstrual bleeding. However, typical pelvic examination findings include a fixed, immobile uterus; rectovaginal nodularity; and an adnexal mass (eg, endometrioma). Endometriosis (Choice C) Patients with hypothyroidism typically have irregular menses (eg, amenorrhea, oligomenorrhea) rather than regular, heavy menses. (Choice D) Leiomyomas can cause heavy menstrual bleeding and dysmenorrhea. However, they also present with an irregularly shaped uterus on examination. Leiomyomas (Choice E) Patients in perimenopause can have heavy menstrual bleeding, fatigue, and sleep disturbances. However, perimenopause is unlikely in this patient, given her regular (ovulatory) menses and well-rugated (estrogenized) vagina. Educational objective: Adenomyosis presents with regular, heavy menses; dysmenorrhea; and a uniformly enlarged, globular uterus. The diagnosis is made clinically and definitive treatment is via hysterectomy. References: Adenomyosis and abnormal uterine bleeding (AUB-A)-pathogenesis, diagnosis, and management. (http://www.ncbi.nlm.nih.gov/pubmed/27810281) Adenomyosis: a systematic review of medical treatment. (http://www.ncbi.nlm.nih.gov/pubmed/27379972)

A 46-Year-Old Woman, Gravida 2 Para 2, Comes to the Office