A 46-year-old woman comes to the office for evaluation of heavy menstrual bleeding. The patient's menses previously occurred every 29 days and consisted of 4 days of moderate bleeding. However, for the past year her menses have occured every 27 days and have become increasingly heavy, consisting of 5 days of heavy bleeding. During the first 2 days of her menstrual period, the patient changes her tampon every 1-2 hours and often soaks through her clothes. Her menses have also become increasingly painful and unrelieved by ibuprofen, and she now has constant, dull pelvic pain between menses. The patient has had 3 cesarean deliveries and a bilateral tubal ligation. Blood pressure is 110/70 mm Hg and pulse is 92/min. BMI is 28 kg/m². Bimanual examination reveals a soft, tender, globular uterus that measures 11 weeks in size. Urine pregnancy test is negative. Hemoglobin is 9.8 g/dL and platelets are 180,000/mm³. Which of the following is the most likely cause of this patient's symptoms?

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Explanation: 11ec25c8_d263_b7df_bc81_65c9f09d3a00_MD0003_00 This patient most likely has adenomyosis - a disorder caused by an abnormal collection of endometrial glands and stroma within the uterine myometrium. Adenomyosis typically presents in multiparous women age >40 with prior uterine surgery (eg, cesarean delivery). Clinical features of adenomyosis are as follows: endometrial glands and stroma New-onset dysmenorrhea due to cyclic accumulation of endometrial glands and stroma within the myometrium during menses. Continued endometrial gland accumulation causes a symmetrically enlarged (globular) uterus that is boggy and tender but does not exceed 12 weeks in size. The symmetrically enlarged uterus increases the endometrial cavity surface area, resulting in the concomitant heavy menstrual bleeding (eg, anemia) typically seen in these patients. As repeated menstrual cycles continue to cause endometrial shedding within the myometrium, patients often progress from dysmenorrhea to chronic, dull pelvic pain. Definitive diagnosis of adenomyosis is made histologically after hysterectomy, which is also the treatment for patients who do not improve with conservative management (eg, oral contraceptives). (Choice B) Endometrial hyperplasia typically presents with irregular menstrual or postmenopausal bleeding rather than heavy, regular menses and dysmenorrhea. (Choice C) Endometriosis can cause chronic pelvic pain and dysmenorrhea. In contrast to this patient, those with endometriosis typically have a small, nontender uterus that is immobile (eg, fixed). Endometriosis (Choice D) Gestational trophoblastic disease (eg, hydatidiform mole, choriocarcinoma) can cause heavy menstrual bleeding and an enlarged uterus; however, patients typically have an elevated hCG (ie, positive pregnancy test), making this diagnosis less likely. (Choice E) Women going through menopause can have heavy menstrual bleeding; however, the bleeding pattern is irregular and there is no associated uterine tenderness. (Choice F) Leiomyomata uteri (fibroids) commonly cause heavy menstrual bleeding. However, although patients may experience pelvic pressure, chronic pelvic pain is uncommon. In addition, fibroids cause a firm, irregularly enlarged uterus. Leiomyomata uteri Educational objective: Adenomyosis typically presents in women age >40 with chronic pelvic pain, dysmenorrhea, and heavy menstrual bleeding. On physical examination, the uterus is symmetrically enlarged, boggy, globular, and tender. References: An update on adenomyosis. (http://www.ncbi.nlm.nih.gov/pubmed/23246186) Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/29566850)

A 46-Year-Old Woman Comes to the Office for Evaluation of Heavy