Adenomyosis — structured oral station (12 minutes)

Opening prompt — "What is the most likely diagnosis and where does it sit in the FIGO classification?"

Model response — definition and classification: ^[1]

• "Her history of progressively heavier and more painful periods, deep dyspareunia and a tender, boggy, globally enlarged uterus is the classic triad of adenomyosis."
• "Adenomyosis is endometrial glands and stroma within the myometrium with adjacent smooth-muscle hyperplasia. It is the A of FIGO PALM-COEIN — a structural cause (AUB-A)."^[1]

Probe 1 — "How do you confirm the diagnosis non-invasively?"

• "Transvaginal ultrasound first, using the MUSA-consensus features: a globular uterus, asymmetrical myometrial thickening with the posterior wall classically thicker, myometrial cysts, hypoechogenic islands, fan-shaped shadowing, linear striations and an irregular endomyometrial junction."
• "MRI is second-line, for problem-solving — when fibroids coexist and obscure the picture, or before fertility-sparing surgery. The threshold is a junctional-zone thickness of at least 12 mm on T2-weighted MRI (Reinhold)."
• "Pooled accuracy is TVUS about 72 percent sensitive and MRI about 77 percent (Champaneria)."^[2][3]

Probe 2 — "Her TVUS shows coexisting fibroids. Does that change your approach?"

• "It doesn't change the diagnosis but it does remind me of the coexistence trap. Adenomyosis, fibroids and endometriosis frequently coexist, and finding one lesion does not finish the case."
• "I quantify the burden of each — the FIGO location of the fibroids decides whether a fibroid is the bleeder (submucous, LSM, bleed most), and I finish the PALM-COEIN workup before operating."^[1]

Probe 3 — "She has completed her family. What is your management?"

• "First-line is the levonorgestrel intrauterine system (LNG-IUS) — a 2025 systematic review of 28 studies confirms it improves dysmenorrhoea, bleeding, uterine volume, endometrial thickness and quality of life."
• "If response is incomplete I add a GnRH analogue with add-back or dienogest. If medical therapy fails, hysterectomy is the definitive cure — symptoms resolve completely."
• "She is not a candidate for fertility-sparing surgery; she is a candidate for definitive hysterectomy if medical therapy fails."^[4]

Probe 4 — "She is worried she will need a hysterectomy. What do you say?"

This is a scored communication domain — demonstrate it out loud: ^[4]

• Move to her eye level, use her name, acknowledge the fear: "Most women with adenomyosis do well on the LNG-IUS — many avoid surgery entirely. We start there and reassess in three to six months. Hysterectomy is the backstop, not the starting point."
• Offer a clear plan, timeline and a named contact for between visits.^[4]

Probe 5 — "How would your approach differ in a 32-year-old seeking fertility?"

• "In a woman seeking fertility, I counsel on the adverse obstetric outcomes (miscarriage, preterm birth, fetal-growth restriction), and I prioritise medical suppression (LNG-IUS, dienogest) before ART."
• "Fertility-sparing surgery (adenomyomectomy) is an option for focal disease — pooled pregnancy rate about 50 percent — but it carries recurrence and uterine-rupture risk and is not first-line."^[4]