A 42-year-old woman, gravida 2 para 2, comes to the office for evaluation of pelvic pain. The patient's menses are painful, with heavy bleeding that requires her to change her tampon every hour during the first 2 days. She did not have painful menstrual periods until a few years ago. The pelvic pain used to subside after menses but has become constant over the past few months and is unrelieved by ibuprofen. Her menstrual cycles are regular, occur every 28-30 days, and last 4 days. She has had no dysuria, urinary frequency, or constipation. The patient had a tubal ligation after her last delivery. She has not had cervical cancer screening within the past 5 years and is not sexually active. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 78/min. Examination shows a boggy uterus that is tender to palpation. Which of the following additional findings is most likely present in this patient?
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This patient's chronic pelvic pain and heavy menstrual bleeding are most likely due to adenomyosis, a condition in which endometrial glands and stroma accumulate abnormally within the uterine myometrium. Adenomyosis typically occurs in multiparous women age >40 and is characterized by new-onset dysmenorrhea due to the cyclic shedding of the endometrium within the myometrium. The continued accumulation of endometrial tissue within the myometrium causes an increase in the endometrial cavity surface area (resulting in heavy menstrual bleeding) and progression to chronic pelvic pain. The entrapped endometrial tissue within the uterine myometrium results in a boggy, tender uterus on examination; it also induces myometrium hypertrophy, which causes a concentric or symmetrically enlarged uterus.
The initial workup of suspected adenomyosis consists of pelvic ultrasonography and/or MRI. A definitive diagnosis is made histologically after hysterectomy, which is also the treatment for patients who do not improve with conservative management (eg, oral contraceptives, progestin-releasing intrauterine device).
(Choice A) An exophytic cervical mass due to cervical cancer may cause heavy vaginal bleeding; however, the bleeding is typically irregular rather than cyclic as with menstruation.
(Choice B) An enlarged, irregularly shaped uterus is common with uterine leiomyomata (fibroids). Fibroids can cause heavy menstrual bleeding; however, the uterus is typically firm (not boggy) and nontender.
(Choice C) Pelvic inflammatory disease can cause chronic pelvic pain and mucopurulent cervical discharge. It does not cause heavy menstrual bleeding and is unlikely in patients who are not sexually active.
(Choices D and F) Posterior cul-de-sac nodularity and adnexal masses (ie, endometriomas) can occur in women with endometriosis due to endometrial implants outside the uterus. This condition typically presents with dysmenorrhea and chronic pelvic pain in younger women (age 25-35). Because endometriosis causes endometrial implants outside (rather than within) the uterine musculature, it does not cause a boggy uterus.
Educational objective:
Adenomyosis typically presents in women age >40 and is characterized by dysmenorrhea; heavy menstrual bleeding; progressive chronic pelvic pain; and a boggy, tender, symmetrically enlarged uterus.