The patient’s symptoms, biopsy, and sonogram findings are typical of adenomyosis, the presence of endometrium within the myometrium.
Adenomyosis usually presents in middle-aged females. Symptoms include dysmenorrhea, menorrhagia, and pelvic pain. Uterine enlargement is due to myometrial hyperplasia. Transvaginal sonogram reveals an enlarged, soft, and tender uterus. On microscopic examination, irregular nests of endometrial stroma are arranged within the myometrium, marring the typically sharply demarcated endomyometrial interface. The condition is benign. Treatment is hysterectomy.
Valentini et al. review the imaging and diagnosis of adenomyosis. Adenomyosis is a pathological gynecological condition characterized by benign invasion of the endometrium into the myometrium. They emphasize it is often misdiagnosed or is not easily recognised, despite the fact that it is responsible for disabling symptoms such as menorrhagia, abnormal uterine bleeding, dysmenorrhoea and infertility in premenopausal women.
Kramer et al. discuss the indications for a hysterectomy, of which adenomyosis is one. There is no universally accepted set of criteria regarding the appropriate indications for hysterectomy. The main indications for hysterectomy include: uterine leiomyomas, dysfunctional uterine bleeding, endometriosis/adenomyosis, chronic pelvic pain and genital prolapse. Current literature, however, routinely recommends conservative management of most nonmalignant gynelogic conditions, with hysterectomy reserved for refractory cases.
Illustration A shows an endoscopic view of adenomyosis. Illustration B is a histology specimen that shows irregular nests of endometrial stroma arranged within the myometrium.
Answer 2: Endometriosis is characterized by endometrial glands and stroma in locations outside of the uterus.
Answer 3: Endometritis is inflammation of the endometrium associated with bacterial infection. Symptoms include fever and uterine tenderness. Fever is not present in this patient.
Answer 4: Leiomyoma is a common benign uterine smooth muscle tumor. Tissue biopsy includes a whirled pattern of smooth muscle bundles.
Answer 5: Endometrial carcinoma is most often present in postmenopausal females. Tumor biopsy reveals dysplastic, invasive endometrial tissue.
Kramer MG, Reiter RC. Hysterectomy: indications, alternatives and predictors. Am Fam Physician. 1997 Feb 15;55(3):827-34. Review. Erratum in: Am Fam Physician 1997 Apr;55(5):1586. PubMed PMID: 9048505.
PMID:9048505 (Link to Abstract)
Valentini AL, Speca S, Gui B, Soglia G, Miccò M, Bonomo L. Adenomyosis: from the sign to the diagnosis. Imaging, diagnostic pitfalls and differential diagnosis: a pictorial review. Radiol Med. 2011 Dec;116(8):1267-87. Epub 2011 Sep 2. English, Italian. Erratum in: Radiol Med. 2011 Dec;116(8):1314. Soglia, B G
PMID:21892720 (Link to Abstract)
USMLE World Step 1 Qbank Question #1957. Copyright © USMLEWorld, LLC 2012