A 48-year-old woman, gravida 1 para 1, comes to the office for evaluation of increasingly heavy menses. For the last 6 months, her menses have lasted for 4-5 days, occurring every 20-25 days, with heavy bleeding, cramps, and passage of clots. Her last menstrual period was 2 days ago. She had one cesarean delivery 20 years ago for the birth of her daughter and states she does not desire any more pregnancies. She takes lisinopril for hypertension, which is well-controlled. She does not drink alcohol or use tobacco or illicit drugs. Temperature is 37.1° C (98.6° F), blood pressure 118/72 mmHg, pulse 112 beats/min, and body mass index (BMI) is 26 kg/m2. On physical examination, the patient appears pale and fatigued. On pelvic examination, the uterus is mobile and appears uniformly enlarged. Speculum examination reveals a normal vagina and cervix. Transvaginal ultrasound is performed reveals an enlarged uterus and asymmetric thickening of the myometrium consistent with adenomyosis.
C) Hysterectomy
The correct choice of management for her would be a hysterectomy. The patient is likely suffering from adenomyosis, a condition characterized by the abnormal presence of endometrial glands within the myometrium of the uterus leading to dysmenorrhea and heavy but regular menstrual cycles. The loss of blood can lead to anemia, possibly present in this patient given her appearance as pale and fatigued. Adenomyosis is usually seen in women, over the age of 40 years. Transvaginal ultrasound is the first-line imaging for evaluation of an enlarged uterus, abnormal uterine bleeding, and/or pelvic pain. MRI can also be used but is typically reserved for patients in whom it is important to distinguish between focal and diffuse adenomyosis or between focal adenomyosis and leiomyomas. Histopathology can provide definitive diagnosis of adenomyosis by showing endometrial glands within the myometrium. Endometrial biopsy is not informative in the diagnosis of adenmyosis but is often required when abnormal uterine bleeding is present in order to exclude endometrial hyperplasia or carcinoma. For women with symptomatic adenomyosis who have completed childbearing, hysterectomy is the definitive treatment option.
Answer choice A: Expectant management, is incorrect. This is usually not considered for cases of adenomyosis as a large amount of blood loss leads to anemia, fatigue, and discomfort to the patient and would no be improved with expectant management.
Answer choice B: Fallopian tube ligation, is incorrect. This has no effect on the disease pathology with adenomyosis since the fallopian tubes are not part of the uterus.
Answer choice D: Intrauterine device, is incorrect. While an intrauterine device containing progesterone might be used to alleviate symptoms, it is usually part of management in women who desire future childbearing. For women who have completed childbearing and are symptomatic, hysterectomy is the definitive treatment option.
Answer choice E: Oral contraceptive pills, is incorrect. Oral contraceptive pills may be tried as a second-line treatment in symptomatic adenomyosis in patients who desire future childbearing, they are not the treatment of choice for symptomatic patients who have completed childbearing.
Key Learning Point
For women with symptomatic adenomyosis who have completed childbearing, hysterectomy is the definitive treatment option.
