A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 44-year-old G2P2 African American woman presents to her gynecologist for dysmenorrhea. She reports that for the past few months, she has been having severe pain during her menses. She also endorses menstrual bleeding that has been heavier than usual. The patient reports that her cycles are regular and occur every 30 days, and she denies both dyspareunia and spotting between her periods. Her last menstrual period was two weeks ago. In terms of her obstetric history, the patient had two uncomplicated pregnancies, and she had no difficulty becoming pregnant. She has never had an abnormal pap smear. Her past medical history is otherwise significant for hyperlipidemia and asthma. On physical exam, the patient’s uterus is tender, soft, and enlarged to the size of a pregnant uterus at 10 weeks of gestation. She is non-tender during vaginal exam, without cervical motion tenderness or adnexal masses. Her BMI is 24 kg/m2. A urine pregnancy test is negative.
Which of the following is the most likely diagnosis for this patient?
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A
Hyperplastic overgrowths of endometrial glands and stromaIncorrect. Hyperplastic overgrowth of endometrial glands and stroma describes endometrial hyperplasia, which produces abnormal bleeding but not a tender, diffusely enlarged uterus.
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B
Malignant invasion of endometrial cells into uterine myometriumIncorrect. Malignant invasion of endometrial cells into myometrium describes endometrial carcinoma, which usually presents in postmenopausal women with postmenopausal bleeding.
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C
Presence of endometrial glands and stroma in uterine myometriumCorrect. Endometrial glands and stroma within the myometrium define adenomyosis, which causes dysmenorrhea, menorrhagia, and a tender, boggy, diffusely enlarged uterus.
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D
Presence of endometrial glands and stroma outside the uterusIncorrect. Endometrial tissue outside the uterus defines endometriosis, which typically presents with dyspareunia, infertility, and a normal or fixed uterus, not a boggy enlarged one.
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E
Benign smooth muscle tumors arising from the myometriumIncorrect. Benign smooth muscle tumors of the myometrium describe leiomyomas (fibroids), which typically produce a firm, irregularly enlarged uterus rather than the soft, boggy, tender uterus of adenomyosis.
↑ Tap an answer to reveal the reasoning
Answer: C. A multiparous African-American woman in her 40s with progressive dysmenorrhea, menorrhagia, and a tender, soft, diffusely enlarged "boggy" uterus (consistent with a 10-week pregnancy) has ADENOMYOSIS. Adenomyosis is the presence of endometrial glands and stroma within the uterine myometrium - the ectopic glands cyclically respond to hormonal changes, producing focal microhemorrhage, smooth muscle hypertrophy, and a diffusely enlarged, tender uterus.
Distinguish from the other options:
- ENDOMETRIOSIS is endometrial glands and stroma OUTSIDE the uterus (ovaries, peritoneum, cul-de-sac), causing dyspareunia, dyschezia, infertility, and cyclic pelvic pain with a normal or fixed uterus.
- LEIOMYOMAS (fibroids) produce a firm, irregularly enlarged uterus (not diffusely soft and tender) and are very common in African-American women.
- ENDOMETRIAL HYPERPLASIA is excessive endometrial glandular growth from unopposed estrogen, presenting with abnormal uterine bleeding but a normal-sized uterus.
- ENDOMETRIAL CARCINOMA invades the myometrium but usually presents with postmenopausal bleeding.
Diagnosis was historically made post-hysterectomy on histology, but MRI now provides reliable preoperative diagnosis. Treatment is medical (NSAIDs, hormonal contraceptives, levonorgestrel IUD, GnRH agonists) or hysterectomy as definitive therapy.
**Why each option:**
**A.** Hyperplastic overgrowth of endometrial glands and stroma describes endometrial hyperplasia, which produces abnormal bleeding but not a tender, diffusely enlarged uterus.
**B.** Malignant invasion of endometrial cells into myometrium describes endometrial carcinoma, which usually presents in postmenopausal women with postmenopausal bleeding.
**C.** Correct. Endometrial glands and stroma within the myometrium define adenomyosis, which causes dysmenorrhea, menorrhagia, and a tender, boggy, diffusely enlarged uterus.
**D.** Endometrial tissue outside the uterus defines endometriosis, which typically presents with dyspareunia, infertility, and a normal or fixed uterus, not a boggy enlarged one.