Adenomyosis — structured SAQ (15 marks)

(a) Definition and classification (2 marks)

One mark per point. ^[1]

• Definition: adenomyosis is the presence of endometrial glands and stroma within the myometrium with adjacent smooth-muscle hyperplasia.
• Classification: it is the A of FIGO PALM-COEIN — a structural cause of abnormal uterine bleeding (AUB-A).^[1]

(b) Imaging features and MRI threshold (5 marks)

One mark per point, maximum five. ^[2][3][4]

• MUSA-consensus TVUS features (named):
  • Indirect: globular enlarged uterus, asymmetrical myometrial thickening (posterior wall classically thicker), fan-shaped shadowing.
  • Direct: myometrial cysts, hypoechogenic islands, linear striations, irregular endomyometrial junction.
• Diagnostic accuracy: TVUS pooled sensitivity about 72 percent and specificity about 81 percent; MRI about 77 percent and 89 percent (Champaneria).
• MRI threshold: junctional-zone thickness of at least 12 mm on T2-weighted MRI (Reinhold); the mean JZ in adenomyosis is about 15 mm versus 8 mm without.
• Biopsy does not diagnose adenomyosis; it excludes coexisting malignancy. Histology of a hysterectomy specimen is the historical gold standard, no longer required.^[2][4]

(c) Differential against fibroids and endometriosis (3 marks)

One mark per point. ^[1][2]

• Adenomyosis vs fibroids: adenomyosis gives a tender boggy uterus with dysmenorrhoea; fibroids give a firm irregular uterus with discrete masses (FIGO location, not size, predicts bleeding).
• Adenomyosis vs endometriosis: endometriosis is endometrial tissue OUTSIDE the uterus — dyschezia, dysuria, nodularity; coexistence is common.
• Coexistence trap: all three frequently coexist; finish the PALM-COEIN workup and quantify the burden of each before operating.^[1][2]

(d) Stepwise management (5 marks)

One mark per point, maximum five. ^[5][6]

• First-line: the levonorgestrel intrauterine system (LNG-IUS) — improves dysmenorrhoea, bleeding, uterine volume, endometrial thickness and quality of life; combination with GnRH analogues is more effective than LNG-IUS alone.
• Adjunctive medical: GnRH analogues (with add-back), oral progestins and dienogest; NSAIDs and tranexamic acid for symptom relief.
• Uterus-sparing options (fertility intent): adenomyomectomy (pooled pregnancy rate about 50 percent), HIFU, UAE — all carry recurrence and uterine-rupture risk.
• Definitive endpoint: hysterectomy is the cure for women who have completed childbearing with refractory disease.
• Principle: shared decision-making weighing symptom burden, fertility intent, age and acceptability.^[5][6]