Eduovisual
Female Reproductive & Breast
Adenomyosis: diagnosis and management
— Classically a multiparous woman aged 35–50, though MRI/TVUS data show it occurs across reproductive ages including nulliparas.
— Prior uterine surgery (C-section, D&C, myomectomy), tamoxifen use, early menarche, short cycles, elevated estrogen exposure, smoking (modest).
— Frequently coexists with leiomyomas (~50%) and endometriosis (~80% of severe cases) — overlap clouds the clinical picture.
— Triad of heavy menstrual bleeding (HMB) + progressive dysmenorrhea + diffusely enlarged, boggy, tender uterus in a 40-something multipara.
— Chronic pelvic pain that worsens premenstrually and persists into menses.
— Dyspareunia, especially deep; secondary infertility or recurrent pregnancy loss without other explanation.
— Failure of NSAIDs and standard combined OCPs to control cyclic pain/bleeding.
— Disrupted endometrial–myometrial junctional zone → ectopic glands → cyclic bleeding within myometrium → hypertrophy, fibrosis, neuroangiogenesis → pain and bulk symptoms.
— Estrogen-driven; aromatase is overexpressed locally, supporting hormonal therapy rationale.
— A leading driver of hysterectomy in women >40; under-recognized in primary care.
— Quality-of-life impact (work absenteeism, anemia, mood) is substantial and should anchor shared decision-making.
Board pearl: the classic stem is a 40-year-old multipara with menorrhagia, severe dysmenorrhea, and a symmetrically enlarged, tender, "boggy" uterus — that's adenomyosis until imaging proves otherwise. Compare to fibroids: enlarged but firm and nontender.
— Heavy menstrual bleeding — quantify with pad/tampon count, flooding, clot size >1 inch, need to change overnight; screen for iron deficiency symptoms (fatigue, pica, restless legs).
— Dysmenorrhea — progressive over years, often starts 1–2 days before menses and persists through it; poorly responsive to NSAIDs.
— Chronic pelvic pain — dull, pressure-like, may radiate to low back or thighs; can become non-cyclic with advanced disease.
— Dyspareunia — typically deep, positional; helps differentiate from vulvodynia or vaginismus.
— Multiparity, prior uterine instrumentation (C-section, evacuation of retained products, hysteroscopic resection).
— Subfertility or recurrent miscarriage — junctional zone disruption impairs implantation and uterine contractility.
— Failed prior hormonal therapy or persistent bleeding on COCs/progestins.
— Cyclic pain + HMB + boggy enlarged uterus → adenomyosis.
— Cyclic pain + HMB + firm nodular uterus → leiomyoma.
— Cyclic pain + dyschezia/dysuria + normal-size uterus + nodular cul-de-sac → endometriosis.
— Intermenstrual bleeding + postcoital bleeding → think polyp, cervical pathology, malignancy, not adenomyosis.
— Postmenopausal bleeding, rapid uterine growth, weight loss → exclude endometrial or uterine sarcoma before attributing to adenomyosis.
— Bleeding with anemia (Hb <10) or hemodynamic symptoms → expedite workup, do not just trial OCPs.
— Work/school days missed, sexual function, depression/anxiety screen (PHQ-2/GAD-2), contraceptive needs, desire for future fertility — these drive management choice.
Step 3 management: in any reproductive-age woman with HMB, always obtain a pregnancy test and CBC first before launching into hormonal therapy or imaging — a one-line order that examiners reward.
— Vital signs: tachycardia, orthostatic changes suggest acute or chronic blood loss anemia — adenomyosis can cause Hb in the 6–8 range over months.
— Pallor of conjunctivae and palmar creases, koilonychia, angular cheilitis → iron deficiency clues.
— BMI and body habitus — obesity influences imaging quality, anesthetic risk, and unopposed estrogen exposure (concurrent endometrial pathology risk).
— Suprapubic fullness; uterus may be palpable above the pubic symphysis when >12-week size.
— Diffuse tenderness without rebound or guarding; absence of peritoneal signs argues against acute pathology.
— Speculum: rule out cervical lesions, polyps, vaginal source of bleeding; assess for active bleeding and clots.
— Bimanual: classic findings are a symmetrically enlarged, globular, "boggy" (soft), and diffusely tender uterus, often described as 8–12 week size.
— Mobility: usually mobile unless coexisting endometriosis causes adhesions and a fixed, retroverted uterus.
— Adnexa: should be nontender and non-enlarged; tender adnexa or nodularity of the uterosacrals → think endometriosis or PID.
— Adenomyosis: symmetric, boggy, tender.
— Fibroids: asymmetric, firm, nodular ("lumpy-bumpy"), usually nontender unless degenerating.
— Pregnancy: symmetric, soft (Hegar sign), nontender, positive βhCG.
— Endometrial cancer: uterus often normal-size or slightly enlarged; bleeding is the dominant sign, exam can be unremarkable.
— Stable + chronic HMB → outpatient workup.
— Tachycardia, hypotension, Hb <7, or active heavy bleeding → ED triage, IV access, type and screen, IV fluids, consider IV estrogen or tranexamic acid.
Key distinction: a tender, boggy, symmetrically enlarged uterus distinguishes adenomyosis from the firm, nontender, irregular uterus of leiomyomas — exam alone often nails the differential.
— Urine or serum β-hCG — mandatory before imaging or hormonal therapy in any reproductive-age woman with abnormal bleeding.
— CBC with differential — quantify anemia; microcytic indices suggest iron deficiency.
— Ferritin, iron, TIBC, transferrin saturation — confirm IDA; ferritin <30 ng/mL is diagnostic in this setting.
— TSH, prolactin — rule out endocrine causes of AUB (PALM-COEIN "O" — ovulatory dysfunction).
— Coagulation studies (PT/PTT, vWF panel) in adolescents or women with HMB since menarche, or family history of bleeding.
— Type and screen if heavy active bleeding or planned procedure.
— Endometrial biopsy in any woman ≥45 with AUB, or <45 with risk factors (obesity, unopposed estrogen, PCOS, tamoxifen, Lynch syndrome, persistent bleeding despite therapy) — to exclude hyperplasia/carcinoma before attributing symptoms to adenomyosis.
— Best initial test; sensitivity ~75–85%, specificity ~85%.
— Adenomyosis features (MUSA consensus):
— Useful when distinguishing intracavitary lesions (polyps, submucosal fibroids) from adenomyosis.
CCS pearl: order urine β-hCG, CBC, ferritin, TSH, and TVUS as your opening move for any reproductive-age woman with HMB and dysmenorrhea — these five orders cover the majority of structural and systemic causes and let you justify the next step on the exam.
— Indications: inconclusive TVUS, coexistent large fibroids obscuring the uterus, surgical planning (especially uterine-sparing procedures), or suspected deep infiltrating endometriosis.
— Key MRI criteria:
— Adenomyoma: ill-defined margins, minimal mass effect, embedded cystic/T2-bright spots, translesional vessels.
— Leiomyoma: well-circumscribed, pseudocapsule, peripheral vascularity, displaces rather than infiltrates.
— Not diagnostic for adenomyosis itself but useful to exclude endometrial polyps, submucosal fibroids, hyperplasia, or carcinoma when bleeding persists despite a presumptive diagnosis.
— Can permit directed biopsy.
— Endometrial glands and stroma >2.5 mm (or one low-power field) below the endometrial–myometrial junction.
— Obtained only at hysterectomy or, rarely, deep myometrial biopsy; not required to begin medical management.
— CA-125 may be elevated but is nonspecific — not used for diagnosis or screening; can confound if ovarian mass is also present.
— Reproductive endocrine workup (AMH, day-3 FSH) if infertility is the dominant complaint.
Board pearl: you do not need histology to diagnose adenomyosis clinically — a consistent history plus TVUS or MRI findings (JZ ≥12 mm) are sufficient to initiate treatment. Save hysterectomy-based confirmation for women who actually need definitive therapy.
— Heavy menstrual bleeding (HMB) only?
— Dysmenorrhea / chronic pelvic pain dominant?
— Both bleeding and pain?
— Subfertility a priority?
— Definitive treatment desired (childbearing complete)?
— Wants future fertility: avoid endometrial ablation and hysterectomy; use medical therapy, consider conservative surgery (adenomyomectomy) only in refractory focal disease.
— Fertility complete, wants uterine preservation: LNG-IUD, ablation (selected), or uterine artery embolization (UAE).
— Fertility complete, definitive cure desired: hysterectomy is the only curative option.
— First line (medical): NSAIDs + tranexamic acid for acute symptom relief; LNG-IUD (52 mg levonorgestrel) for sustained bleeding and pain control; combined oral contraceptives (continuous or cyclic) as alternative.
— Second line: oral progestins (norethindrone, dienogest), GnRH antagonists (elagolix, relugolix combo) with add-back therapy, GnRH agonists (leuprolide) short-term.
— Third line / refractory: uterine artery embolization, MR-guided focused ultrasound, adenomyomectomy.
— Definitive: hysterectomy (vaginal, laparoscopic, or abdominal depending on uterine size and surgeon expertise).
— Set expectations: medical therapy controls symptoms but does not eliminate disease.
— Address anemia in parallel — oral or IV iron; transfuse if symptomatic or Hb <7.
— Reassess at 3 and 6 months; switch therapy if no improvement.
Step 3 management: in a 42-year-old multipara with HMB, dysmenorrhea, Hb 9.5, and adenomyosis on TVUS who has completed childbearing → place an LNG-IUD as first-line uterine-preserving therapy and start oral iron — covers both pain and bleeding while restoring hemoglobin.
— First-line for HMB + dysmenorrhea in adenomyosis; reduces blood loss 70–90%, often induces amenorrhea by 6–12 months.
— Causes endometrial atrophy and decidualization of ectopic foci; shrinks junctional zone on MRI.
— Side effects: irregular spotting (months 1–6), expulsion risk higher in enlarged uteri (counsel and re-image at 6 weeks).
— Effective for 8 years for contraception, ~5 years for HMB indication.
— Continuous or extended-cycle dosing preferred to minimize withdrawal bleeds and pain.
— Avoid in migraine with aura, smokers ≥35, uncontrolled HTN, VTE history, breast cancer.
— Norethindrone acetate 5 mg daily, medroxyprogesterone, or dienogest 2 mg daily (well-studied in adenomyosis/endometriosis).
— Useful when IUD contraindicated or not desired.
— 1,300 mg PO TID during heaviest 5 days of menses; reduces bleeding ~40%.
— Avoid with active thromboembolism, hormonal contraception in high-risk patients (relative).
— Mefenamic acid, naproxen, ibuprofen — start 1–2 days before menses, continue through heaviest days; reduce bleeding 20–30% and dysmenorrhea.
— Elagolix and relugolix + estradiol + norethindrone combo — induce hypoestrogenic state, shrink uterus, control bleeding/pain.
— Add-back therapy mitigates BMD loss and vasomotor symptoms; limit duration per labeling (typically 24 months).
— Useful as bridge before surgery to shrink uterus and correct anemia; limited to 6 months without add-back due to BMD loss.
Board pearl: the LNG-IUD is the highest-yield single answer for adenomyosis-related HMB in a woman who wants uterine preservation — beats COCs and oral progestins in head-to-head bleeding reduction.
— Interventional radiology occludes bilateral uterine arteries with microspheres → ischemic shrinkage of adenomyotic tissue.
— ~75% symptom improvement at 1 year; 50–60% durable at 3–5 years.
— Best for women with completed childbearing who want uterine preservation; fertility outcomes after UAE are inferior to surgery and not recommended if pregnancy is desired.
— Contraindications: active pelvic infection, suspected malignancy, pregnancy.
— Post-procedure: expect post-embolization syndrome (pain, low-grade fever, nausea ×3–7 days) — treat with NSAIDs, opioids, antiemetics, hydration.
— Non-invasive thermal ablation of focal adenomyomas; outpatient, no incisions.
— Best for focal, accessible lesions; less effective in diffuse disease or very large uteri.
— Useful for HMB when adenomyosis is superficial; deeper disease predicts failure and persistent pain.
— Contraindicated if future fertility desired; counsel about contraception post-ablation (pregnancy is high-risk).
— Excision of focal adenomyoma with uterine reconstruction; option for women with infertility and focal disease.
— Risks: uterine rupture in subsequent pregnancy → plan cesarean delivery at term; counsel on recurrence.
— Indicated for refractory symptoms, completed childbearing, or coexisting pathology.
— Routes: vaginal (preferred when feasible), laparoscopic/robotic, abdominal for very large uteri.
— Ovarian conservation favored in premenopausal women unless other indication.
— Perioperative: VTE prophylaxis (mechanical + pharmacologic per Caprini), antibiotic prophylaxis (cefazolin), correct anemia preop.
CCS pearl: if a 47-year-old with refractory adenomyosis fails LNG-IUD and GnRH antagonist after 6 months and has completed childbearing → next best step is hysterectomy, not another medical trial.
— Adenomyosis symptoms typically regress after menopause as estrogen falls; new or persistent bleeding postmenopause is never attributable to adenomyosis alone.
— Any postmenopausal bleeding mandates endometrial biopsy and TVUS (endometrial stripe >4 mm) to rule out hyperplasia/carcinoma — do not anchor on prior adenomyosis diagnosis.
— Tamoxifen users: increased risk of adenomyosis reactivation, endometrial polyps, hyperplasia, and carcinoma; surveillance with symptom-driven workup (not routine TVUS).
— NSAIDs: avoid in CKD stage 3b–5 (eGFR <45) due to AKI risk; if needed, lowest dose, shortest duration, monitor creatinine.
— Tranexamic acid: renally cleared — dose-reduce based on creatinine; contraindicated in severe renal impairment due to accumulation and seizure risk.
— LNG-IUD, COCs, progestins: generally safe in CKD; COCs may worsen hypertension common in CKD — prefer progestin-only.
— Estrogen-containing COCs contraindicated in active liver disease, cirrhosis with decompensation, hepatic adenoma, or history of cholestasis of pregnancy.
— Progestin-only methods and LNG-IUD acceptable.
— GnRH antagonists (elagolix): contraindicated in severe hepatic impairment; dose adjustment for moderate impairment.
— Tranexamic acid: no specific hepatic dose adjustment.
— GnRH agonists/antagonists cause BMD loss; in older perimenopausal women, factor baseline DEXA and add-back therapy.
— Concurrent calcium 1,200 mg + vitamin D 800–1,000 IU recommended.
— HMB worsens; LNG-IUD is the preferred bleeding-control strategy — does not interact with anticoagulation.
Key distinction: premenopausal HMB in adenomyosis is expected; postmenopausal bleeding is not — always biopsy.
— Associated with infertility, recurrent implantation failure, miscarriage, preterm birth, PPROM, placental malposition, and small-for-gestational-age infants.
— Mechanism: disrupted junctional zone peristalsis, abnormal uterotubal transport, altered implantation milieu, inflammatory cytokines.
— Discuss increased obstetric risks; optimize iron stores, control symptoms before conception.
— For ART: long GnRH agonist suppression (2–3 months) before frozen embryo transfer improves live birth rates in women with adenomyosis.
— Avoid endometrial ablation and UAE if pregnancy is desired.
— No specific therapy during pregnancy; manage as higher-risk pregnancy with serial growth scans, cervical length screening, and increased surveillance for preterm labor.
— Post-adenomyomectomy pregnancies: counsel about uterine rupture risk — typically scheduled cesarean at 36–37 weeks depending on extent of myometrial repair.
— Increased risk of postpartum hemorrhage from atony — active management of third stage, uterotonics ready.
— Symptoms may return after lactational amenorrhea ends; LNG-IUD can be placed immediately postpartum or at 6-week visit.
— Adenomyosis is uncommon but underdiagnosed in adolescents; consider in those with severe progressive dysmenorrhea refractory to NSAIDs and COCs, especially with TVUS findings.
— Workup: rule out endometriosis (more common at this age), obstructive müllerian anomalies, bleeding disorders (vWD screening for HMB since menarche).
— Management: NSAIDs, continuous COCs, LNG-IUD (safe and effective in nulliparous adolescents per ACOG).
— Progestin-only methods and LNG-IUD compatible.
— Avoid estrogen-containing COCs until ≥6 weeks postpartum and milk supply established.
Step 3 management: in a 32-year-old with infertility, dysmenorrhea, and MRI-confirmed adenomyosis planning IVF → 2–3 months of GnRH agonist suppression before frozen embryo transfer improves outcomes.
— Chronic HMB drives ferritin depletion; symptoms include fatigue, dyspnea, restless legs, pica, cognitive slowing.
— Treatment: oral iron (ferrous sulfate 325 mg every other day improves absorption and tolerance) for mild–moderate; IV iron (iron sucrose, ferric carboxymaltose) for severe, intolerant, or preoperative repletion.
— Transfusion threshold: symptomatic anemia or Hb <7 (or <8 with cardiac disease).
— Long-standing dysmenorrhea can evolve into non-cyclic chronic pelvic pain with neuropathic features, pelvic floor dysfunction, and opioid risk.
— Multimodal approach: hormonal suppression + pelvic floor PT + neuromodulators (gabapentin, amitriptyline) + behavioral therapy.
— Miscarriage, preterm birth, PPROM, FGR, malpresentation, placenta previa, postpartum hemorrhage.
— Depression, anxiety, sexual dysfunction, relationship strain, work disability — screen with PHQ-9 and validated sexual function tools.
— LNG-IUD: expulsion (higher in enlarged uterus), perforation (rare, ~1/1,000), irregular bleeding early.
— Endometrial ablation: late-onset pain (post-ablation syndrome, hematometra), failure, pregnancy after ablation is high-risk (ectopic, abnormal placentation).
— UAE: post-embolization syndrome, non-target embolization, ovarian failure (~1–5%, higher in >45), fertility impairment.
— Hysterectomy: surgical risks (bleeding, infection, ureteral/bladder/bowel injury, VTE), early ovarian decline even with ovarian preservation, surgical menopause if oophorectomy.
— Adenomyosis is benign; rare reports of malignant transformation. Coexistent endometrial carcinoma can arise within adenomyotic foci — always biopsy persistent abnormal bleeding.
Board pearl: in a woman who had endometrial ablation and now presents with cyclic pain without bleeding, suspect hematometra or post-ablation tubal sterilization syndrome — imaging guides next step.
— Hemodynamic instability from acute heavy bleeding: HR >110, SBP <90, orthostatic symptoms, or active flooding.
— Two large-bore IVs, IV crystalloid, type and crossmatch, CBC, coagulation panel.
— IV tranexamic acid 10 mg/kg or high-dose IV conjugated estrogens (25 mg q4–6h) for acute control.
— Transfuse pRBCs if Hb <7 or symptomatic; correct coagulopathy.
— Severe symptomatic anemia (chest pain, dyspnea, syncope).
— Failed outpatient control of bleeding requiring transfusion.
— Need for IV iron infusion in dedicated infusion center (usually outpatient but admit if comorbidities).
— Planned surgical management with significant comorbidities.
— Gynecology referral for any patient with suspected adenomyosis who fails 3–6 months of primary-care–initiated medical therapy, or has anemia not responding to iron.
— Reproductive endocrinology and infertility (REI) for adenomyosis + infertility, recurrent pregnancy loss, or planned ART.
— Interventional radiology for UAE candidates.
— Hematology for refractory anemia, suspected bleeding disorder, or transfusion dependence.
— Pain medicine / pelvic floor PT for chronic pelvic pain with central sensitization features.
— Postmenopausal bleeding → urgent biopsy.
— Rapidly enlarging uterus, especially in postmenopausal women → MRI and gyn-onc referral for leiomyosarcoma workup.
— Persistent bleeding despite appropriate therapy → reimage and rebiopsy; do not anchor on adenomyosis.
— Suspicion of malignancy on imaging or pathology → gyn-onc referral.
— Document shared decision-making for surgical vs medical therapy.
— Ensure follow-up scheduling before discharge from acute care.
CCS pearl: acute heavy uterine bleeding with Hb 6 and tachycardia → admit, IV access, type and cross, IV TXA or IV conjugated estrogens, transfuse, gyn consult — that's the order set examiners want to see.
— Firm, nodular, asymmetric uterus; HMB common, dysmenorrhea less prominent unless submucosal or degenerating.
— TVUS: well-defined hypoechoic masses with peripheral vascularity.
— Frequently coexist with adenomyosis — finding fibroids doesn't exclude adenomyosis.
— Dysmenorrhea, dyspareunia, dyschezia, infertility; normal-size uterus, tender uterosacrals, fixed retroversion, adnexal endometriomas.
— Often coexists with adenomyosis (~80% in severe cases).
— Intermenstrual bleeding, postcoital bleeding; focal echogenic lesion within cavity on TVUS, confirmed by SIS or hysteroscopy.
— Risk factors: obesity, unopposed estrogen, PCOS, tamoxifen, nulliparity, Lynch syndrome, age ≥45.
— Endometrial stripe thickening on TVUS; biopsy is diagnostic.
— Rapidly enlarging uterus in perimenopausal/postmenopausal women, often painful; MRI shows heterogeneous mass with restricted diffusion.
— Rare but feared — avoid power morcellation in suspected cases.
— Polyps, cervicitis, cervical cancer — postcoital bleeding, abnormal Pap, visible lesion on speculum.
— A subset of adenomyosis presenting as a discrete mass; mimics a fibroid but has ill-defined borders and embedded cystic foci.
— Structural (PALM): Polyp, Adenomyosis, Leiomyoma, Malignancy/hyperplasia.
— Non-structural (COEIN): Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not otherwise classified.
Key distinction: firm, irregular, nontender uterus = fibroids; soft, globular, tender uterus = adenomyosis; normal-size uterus with tender nodular cul-de-sac = endometriosis — three exam phenotypes, three different boards answers.
— Von Willebrand disease is the most common inherited bleeding disorder; suspect in HMB since menarche, easy bruising, epistaxis, family history.
— Screen: PT, PTT, vWF antigen, vWF activity (ristocetin cofactor), factor VIII, platelet function testing.
— Anticoagulant or antiplatelet use, liver disease–related coagulopathy, thrombocytopenia.
— PCOS, hypothalamic amenorrhea, hyperprolactinemia, thyroid disease, perimenopause.
— Workup: TSH, prolactin, androgens, fasting glucose/A1c; ultrasound for ovarian morphology.
— Atrophy more common postmenopausal; endometritis in postpartum or post-instrumentation with fever, tenderness, abnormal discharge.
— Hormonal contraceptives (irregular bleeding), copper IUDs (heavier menses), anticoagulants, antipsychotics affecting prolactin.
— Ectopic pregnancy, threatened/incomplete miscarriage, gestational trophoblastic disease — always exclude with βhCG.
— Cervical motion tenderness, adnexal tenderness, fever, mucopurulent discharge; treat per CDC PID guidelines.
— Interstitial cystitis/bladder pain syndrome: urinary urgency/frequency, suprapubic pain with bladder filling.
— IBS: cramping with altered bowel habits, relief with defecation.
— Diverticulitis, IBD: left lower quadrant pain, GI symptoms.
— Pelvic floor myofascial pain, pudendal neuralgia — reproduce with focused exam.
— Depression, anxiety, prior trauma — amplify pain perception; screen and address.
Board pearl: before attributing HMB to adenomyosis in any teen or young adult, screen for von Willebrand disease — missing it is a classic exam pitfall and a real-world quality issue.
— Iron repletion: ferrous sulfate 325 mg every other day × 3–6 months or until ferritin >50 ng/mL.
— Hormonal suppression: LNG-IUD placement (ideally before discharge or at first follow-up) or continuous COCs/progestins.
— NSAIDs for breakthrough dysmenorrhea (mefenamic acid 500 mg TID during menses).
— Tranexamic acid PRN for heavy menstrual days.
— Plan to reassess in 3 months for symptom control and Hb recovery.
— If oophorectomy in premenopausal woman: discuss hormone therapy to mitigate surgical menopause symptoms and protect bone/cardiovascular health until natural menopause age (~51).
— Resume cervical cancer screening per current guidelines (discontinue if total hysterectomy for benign indication and no history of high-grade dysplasia).
— Continue mammography, colonoscopy, lipid panel, A1c per age-based USPSTF guidelines — gynecologic surgery does not exempt general preventive care.
— Contraception remains necessary if premenopausal; ablation is not contraception and pregnancy post-ablation is high-risk.
— Symptom recurrence common; reassess at 6–12 months.
— Iron-rich diet (heme sources, vitamin C co-ingestion); avoid concurrent calcium or tea with iron doses.
— Regular exercise improves dysmenorrhea (modest evidence).
— Pelvic floor PT for coexisting myofascial pain.
— Ensure influenza, COVID, Tdap, HPV (through age 26, shared decision 27–45) up to date — easy to overlook in symptom-focused visits.
Step 3 management: after discharging a woman post-acute HMB, the highest-yield three-part plan is LNG-IUD + oral iron + 3-month follow-up CBC and symptom check — examiners look for this trio.
— 6 weeks after LNG-IUD placement: confirm strings, address spotting, screen for expulsion (higher risk with enlarged uterus). Ultrasound if strings absent.
— 3 months: assess symptom improvement (bleeding diary, pain scores), check CBC and ferritin.
— 6 months: if no meaningful improvement (≥50% reduction in bleeding/pain), escalate therapy.
— Annually thereafter: review symptoms, contraceptive needs, screening alignment.
— Pictorial Blood Loss Assessment Chart (PBAC), pad/tampon counts, days of bleeding, pain scores (0–10) — quantify response objectively.
— Reticulocyte count at 2 weeks (rising = response).
— Hb at 4–8 weeks; ferritin at 3 months — continue iron until ferritin >50 ng/mL.
— BMD baseline DEXA if anticipated use >6 months; add-back hormonal therapy to minimize loss.
— Monitor for vasomotor symptoms, mood changes, hepatic enzymes (elagolix).
— Hysterectomy: 2- and 6-week post-op visits — wound check, return-to-activity counseling (no heavy lifting or intercourse ×6 weeks), VTE symptom review.
— UAE: 1-week phone check, 3-month imaging if symptoms recur.
— Set realistic expectations: medical therapy controls but does not cure; symptoms recur after cessation.
— Fertility counseling: address timing of childbearing relative to disease progression.
— Mental health: screen for depression/anxiety at each visit; refer when indicated.
— Sexual health: open dialogue about dyspareunia; offer pelvic floor PT, lubricants, vaginal estrogen if hypoestrogenic from GnRH analog.
— Especially important when offering hysterectomy or fertility-affecting interventions.
CCS pearl: at the 3-month follow-up after LNG-IUD placement, the highest-yield orders are CBC, ferritin, and a bleeding/pain assessment — drives the next management step.
— Hysterectomy is irreversible and permanently ends fertility — document detailed counseling about alternatives (LNG-IUD, UAE, GnRH analogs), risks, benefits, and the option of ovarian conservation.
— Discuss psychological and sexual impact; consider age-appropriate hormone therapy if oophorectomy is performed premenopausally.
— In younger patients (<35), obtain second opinion or formal counseling documentation; involve partner per patient's wishes but never require partner consent — this is a board-tested ethics point.
— A patient with decision-making capacity may decline surgery even when medically advised; respect autonomy, document risks of refusal, ensure understanding.
— Adolescents: consider state-specific minor consent laws for reproductive care; involve parents per local statute but respect confidentiality where law permits.
— Discharge after acute HMB requires clear handoff: confirmed PCP follow-up within 1–2 weeks, prescriptions filled, iron started, gyn appointment scheduled, instructions for return precautions (recurrent flooding, syncope, fever, severe pain).
— Medication reconciliation: verify removal of anticoagulants if temporarily held, confirm restart plan.
— FDA warning regarding occult leiomyosarcoma; counsel patients before laparoscopic morcellation; use containment bags when used.
— Adenomyosis is underdiagnosed in Black and minority women; symptoms often dismissed. Equity-aware history-taking and timely imaging reduce diagnostic delay.
— Address cost barriers: LNG-IUD coverage varies, IV iron access depends on insurance.
— Screen for intimate partner violence in chronic pelvic pain visits; trauma history influences pain perception and treatment response.
— Track unintended hysterectomy in young women, perioperative VTE rates, transfusion utilization.
Board pearl: a 28-year-old requesting hysterectomy for adenomyosis after one failed trial of NSAIDs → the correct next step is comprehensive counseling and offer LNG-IUD or other fertility-sparing options first, not immediate surgery, regardless of patient request.
Key distinction: the four uterine bleeding phenotypes — fibroid, adenomyosis, endometrial cancer, coagulopathy — each have a signature stem; memorize the pattern, not the prose.
— "A 42-year-old G3P3 woman presents with 2 years of progressively heavy, painful menses and a symmetrically enlarged, tender uterus. TVUS shows myometrial cysts and a heterogeneous, globular uterus." → Diagnosis: adenomyosis. Best initial treatment: LNG-IUD.
— "MRI shows junctional zone thickness of 14 mm with high-signal foci in the myometrium." → Adenomyosis (not fibroid).
— "She has completed childbearing and failed COCs and oral progestins; symptoms persist with Hb 8.5." → Next step: LNG-IUD (if not tried) or GnRH antagonist with add-back; if refractory after 6 months → hysterectomy.
— "32-year-old with infertility and MRI-confirmed adenomyosis planning IVF." → GnRH agonist suppression 2–3 months before FET.
— "Hb 6.2, HR 118, BP 92/58, flooding through pads." → IV access, fluids, type and cross, IV TXA or IV conjugated estrogens, transfuse, gyn consult.
— "55-year-old with prior adenomyosis presents with new vaginal bleeding." → Endometrial biopsy and TVUS (not "reassure, attributable to old adenomyosis").
— "16-year-old with HMB since menarche, easy bruising, family history of bleeding." → Screen for von Willebrand disease before attributing to structural cause.
— "26-year-old requests hysterectomy after one failed NSAID trial." → Counsel and offer fertility-sparing options first.
— "Post-UAE day 3 with pain, low-grade fever, nausea." → Post-embolization syndrome, treat supportively; not infection.
— "Breast cancer survivor on tamoxifen with new HMB." → Workup with TVUS and endometrial biopsy; do not anchor on adenomyosis.
Step 3 management: the most commonly tested management answer in adenomyosis stems is the LNG-IUD — when in doubt and uterine preservation is desired, that is the right answer.
Adenomyosis is a benign estrogen-driven invasion of endometrial glands into the myometrium that presents with heavy menstrual bleeding, progressive dysmenorrhea, and a symmetrically enlarged, tender, boggy uterus in a 35–50-year-old multipara — diagnosed clinically with TVUS or MRI (junctional zone ≥12 mm), first-line treatment is the levonorgestrel IUD, and the only definitive cure is hysterectomy.
Board pearl: when a stem describes the classic boggy, tender, symmetrically enlarged uterus with heavy painful periods in a 40-year-old who has completed childbearing, the highest-yield next step is placement of a levonorgestrel-releasing IUD — and if she has failed all medical therapy after 6 months, the answer becomes hysterectomy.